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Casework applications to the treatment of the schizophrenic patient: an analytical review of current… Moore, Janet Gordon 1962

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CASEWORK APPLICATIONS TO THE TREATMENT OE THE SCHIZOPHRENIC PATIENT An A n a l y t i c a l Review of Current and C l i n i c a l Practice  Concepts  JANET G. MOORE  Thesis Submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree of MASTER OP SOCIAL WORK i n the School of S o c i a l Work  Accepted as conforming to the standard required f o r the degree of Master of S o c i a l Work  School of S o c i a l Work  1962  The U n i v e r s i t y of B r i t i s h Columbia  In presenting  t h i s thesis i n p a r t i a l f u l f i l m e n t of  the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y available f o r reference and study.  I further agree that permission  for extensive copying of t h i s thesis f o r scholarly purposes may granted by the Head of my Department or by his  be  representatives.  It i s understood that copying or publication of t h i s thesis f o r f i n a n c i a l gain s h a l l not be allowed without my written permission.  Department of  S&jC*-*€ ^  Scr^ZaS  The University of B r i t i s h Columbia, Vancouver 8, Canada. Date  UA*^  iv  ABSTRACT S c h i z o p h r e n i a , the most common of the p s y c h o s e s , i s a c h a l l e n g i n g s u b j e c t f o r the b e g i n n i n g s o c i a l worker i n a psychiatric setting. The purpose o f t h i s study, a f t e r r e v i e w i n g the n a t u r e and cause o f s c h i z o p h r e n i a and i n d i c a t i n g how i t i s c u r r e n t l y t r e a t e d i n mental h o s p i t a l s and c l i n i c s ; i s t o assess (a) whether casework i s an a p p r o p r i a t e t r e a t m e n t method f o r t h i s d i s o r d e r ; and (b) i f so, what m o d i f i c a t i o n of casework i s n e c e s s a r y t o meet the s c h i z o p h r e n i c p e r s o n ' s needs. S c h i z o p h r e n i a i s no l o n g e r r e g a r d e d as a p u r e l y p s y c h i a t r i c concern. C u r r e n t treatment aims a t r e d u c t i o n o f symptoms and improvement i n s o c i a l adjustment o f the s c h i z o p h r e n i c p a t i e n t , not " c u r e " o f the u n d e r l y i n g pathology. A c c o r d i n g t o modern p s y c h i a t r y , the c e n t r a l problem i n s c h i z o p h r e n i a i s the s o c i a l m a l f u n c t i o n i n g o f the p a t i e n t , and s o c i a l workers i n the community as w e l l as i n c l i n i c a l s e t t i n g s are b e i n g c a l l e d upon w i t h i n c r e a s i n g f r e q u e n c y t o a i d i n the treatment o f t h i s d i s o r d e r . As f o u n d a t i o n f o r t h i s study, the o r t h o p s y c h i a t r y l i t e r a t u r e a v a i l a b l e over the p a s t decade on the psychop a t h o l o g y and treatment o f the s c h i z o p h r e n i c has been c r i t i c a l l y r e v i e w e d . Prom t h i s m a t e r i a l and from the p e r s o n a l e x p e r i e n c e o f the w r i t e r i n casework s e r v i c e t o h o s p i t a l i z e d s c h i z o p h r e n i c p a t i e n t s , c u r r e n t c o n c e p t s on the n a t u r e and cause of s c h i z o p h r e n i a are d e f i n e d , and p r e s e n t t r e a t m e n t measures e v a l u a t e d . Casework as a method f o r t r e a t i n g s c h i z o p h r e n i a i s a n a l y z e d , and the phases o f study, s o c i a l d i a g n o s i s , p l a n n i n g and implementing treatment i s a p p l i e d t o the s c h i z o p h r e n i c p a t i e n t ' s c e n t r a l problems, defense mechanisms, and i m p a i r e d e g o - f u n c t i o n i n g . "Ego breakdown" i n s c h i z o p h r e n i a i s a s s e s s e d , and c o n t r a s t e d w i t h the e g o - f u n c t i o n i n g o f the normal, n e u r o t i c and s o c i o p a t h i c p e r s o n a l i t y types. The c o n c l u s i o n s o f t h i s s t u d y can o n l y be a p p l i c a b l e t o s c h i z o p h r e n i a i n g e n e r a l , not t o s p e c i f i c c a s e s . Schizophrenia i s psychogenic i n o r i g i n , o r i g i n a t i n g i n e a r l y c h i l d h o o d when extreme a n x i e t y and i n s e c u r i t y i n the c h i l d are caused by f a u l t y r e l a t i o n s h i p s w i t h the p a r e n t s , and i n p a r t i c u l a r w i t h the mother. The treatment o f c h o i c e f o r s c h i z o p h r e n i a i s psychotherapy, with adjunctive p h y s i c a l t h e r a p i e s used t o reduce symptoms and i n c r e a s e a c c e s s i b i l i t y  V  to personal contact. The supportive treatment method of casework and most of i t s techniques are eminently s u i t e d to t r e a t i n g the schizophrenic p a t i e n t : the modifying treatment method, c l a r i f i c a t i o n , catharsis and i n t e r p r e t a t i o n of underlying c o n f l i c t s , are not. The casework approach to the schizophrenic d i f f e r s decidedly from that used with c l i e n t s possessing stronger egos, who c a l ) t o l e r a t e the anxiety aroused "by self-examination. The goals of casework with the schizophrenic p a t i e n t are support of the cons t r u c t i v e parts of the patient's p e r s o n a l i t y , strengthening of h i s ego-functioning, and maintenance of h i s psychotic defenses u n t i l more constructive defenses are r e b u i l t . The schizophrenic patient's c e n t r a l problems are h i s withdrawal from r e a l i t y due to f e a r , and h i s basic mistrust of people. A r e a l i t y - o r i e n t e d approach, d i r e c t e d to helping the patient cope more e f f e c t i v e l y with everyday problems, i s used to overcome the schizophrenic patient's d i s t r u s t and to renew h i s contact with the r e a l world.  ii  TABLE OE CONTENTS Chapter 1,  The Understanding of Mental I l l n e s s  Mental i l l n e s s : i t s significance as a s o c i a l problem. Factors i n the North American culture which may contribute to mental disturbance. The p r a c t i c e of s o c i a l work i n r e l a t i o n to mental illness. Role of the " p s y c h i a t r i c " s o c i a l worker. Nature and o r i g i n , changing concept, of mental illness. Theories of " f u n c t i o n a l " and "organic" origin. The "organismic" theory of causation. Current " u n i t a r y " concept of mental disturbance. C l a s s i f i c a t i o n of mental i l l n e s s into three main groups. D e s c r i p t i o n of disorders of probable psychogenic o r i g i n . Types of schizophrenic reactions defined. Purpose, focus, method of the present study Chapter 2.  A C l i n i c a l Picture of Schizophrenia  Incidence and age of onset: percentage of schizophrenic patients i n mental h o s p i t a l s ; the most common ages of onset. Relationship of schizophrenia to s o c i a l c l a s s : higher incidence i n lower c l a s s e s ; deprived s o c i a l and psychological background of the schizophrenic. E t i o l o g i c a l theories of E r a e p e l i n , B l e u l e r , Meyer and Ereud; A r i e t i ' s developmental theory of the " s c h i z o i d " and "stormy" types of personality. Onset and e a r l y symptoms: early character changes; symptoms preceding the i n i t i a l attack. Prognosis: hopeful signs; p e r s o n a l i t y d e t e r i o r a t i o n ; v a r i a t i o n i n prognosis according to r e a c t i o n type; response to treatment. Evaluation of treatment methods; psychotherapy the treatment of choice; p h y s i c a l forms of therapy; prevention and after-care  iii Chapter 3«  Casework Treatment: Diagnosis  Study and S o c i a l  The generic method of casework defined. Casework i n the p s y c h i a t r i c s e t t i n g . Casework focus with the schizophrenic p a t i e n t . The study phase: i t s purpose and goal; the i n i t i a l approach to the schizophrenic p a t i e n t ; h i s presenting problems. The s o c i a l diagnostic phase: i d e n t i f i c a t i o n of c e n t r a l problems i n schizophrenia; assessment of ego functioning and defense mechanisms of the schizophrenic p a t i e n t ; comparison with mature, neurotic and sociopathic defenses; evaluation of external s t r e s s e s , l e v e l of s o c i a l f u n c t i o n i n g ; determining motivation and capacity to change, to accept and use help Chapter 4.  Casework Treatment: Implementation  Planning and  Planning treatment with the schizophrenic patient: s e t t i n g r e a l i s t i c and l i m i t e d treatment goals; s e l e c t i n g the appropriate casework treatment method.- S u i t a b i l i t y of casework to t r e a t schizophrenia. Requirements of the caseworker to act as therapist. Planning the structure and course of treatment: timing and spacing of interviews; length of treatment course. Implementing treatment through the casework r e l a t i o n s h i p : B i e s t e k ' s Seven P r i n c i p l e s of r e l a t i o n s h i p applied to the schizophrenic p a t i e n t ' s s p e c i a l needs; e s t a b l i s h i n g i n i t i a l contact; the caseworker's approach; some s p e c i f i c treatment guides; terminating the r e l a t i o n ship Appendix: A.  Bibliography  CASEWORK APPLICATIONS TO THE TREATMENT OE THE SCHIZOPHRENIC PATIENT  An a n a l y t i c a l review of current and c l i n i c a l  practice  concepts  CHAPTER I THE  UNDERSTANDING OF MENTAL ILLNESS  Mental  i l l n e s s today i s a s e r i o u s and a p p a r e n t l y  i n c r e a s i n g s o c i a l problem. one time  According to present  indications,  out o f twelve b a b i e s born i n t h i s c e n t u r y w i l l a t some of i t s l i f e  e n t e r a mental h o s p i t a l .  H a l f o f a l l the  h o s p i t a l beds i n the U n i t e d S t a t e s a r e commonly a s s i g n e d t o the m e n t a l l y i l l , chronically i l l  o f which a p p r o x i m a t e l y  or terminal cases.  1  h a l f prove t o be  Although  comparable  e s t i m a t e s f o r Canada have n o t been made, between n i n e and t h i r t e e n m i l l i o n persons  i n the U n i t e d S t a t e s a r e computed  as s u f f e r i n g from nervous,  mental o r e m o t i o n a l t r o u b l e s .  C e r t a i n l y about one m i l l i o n p a t i e n t s a r e t r e a t e d each y e a r i n approximately  s i x hundred mental h o s p i t a l s and the r a t e p  o f admissions  i s constantly increasing.  I n c r e a s e s i n the r a t e o f h o s p i t a l i z a t i o n cannot  1 O p l e r , M a r v i n K., Ph.d., " C u l t u r a l P e r s p e c t i v e s i n Mental H e a l t h Research," American J o u r n a l o f O r t h o p s y c h i a t r y , v o l . 25 (January 1955). p . 54. 2 A p p e l , Kenneth E . , "Mental H e a l t h and Mental I l l n e s s , " S o c i a l Work Yearbook 1957. American A s s o c i a t i o n o f S o c i a l Workers, New York, 1957» pp. 368-369. T h i s source s t a t e s t h a t the g e n e r a l p o p u l a t i o n o f the U n i t e d S t a t e s i s i n c r e a s i n g a t the r a t e o f t e n p e r cent e v e r y t e n y e a r s : mental h o s p i t a l admissions have i n c r e a s e d f o r t y p e r c e n t i n the p a s t t e n y e a r s .  2 be a t t r i b u t e d s o l e l y to the supposed higher incidence of mental i l l n e s s .  In the past few decades, the normal l i f e -  span has lengthened:  the older group are more prone to  mental disturbance and subsequent h o s p i t a l i z a t i o n .  Skill  i n diagnosis of mental disorder has improved; more persons are being committed to h o s p i t a l s f o r treatment.  In general,  the p u b l i c i s beginning to understand that improvement and recovery are possible i f mental i l l n e s s i s treated e a r l y . Increased p s y c h i a t r i c knowledge of mental disturbance, improved treatment techniques and b e t t e r h o s p i t a l f a c i l i t i e s have encouraged more voluntary admissions.  Although expla-  nations f o r the increased h o s p i t a l i z a t i o n rate can be found, the reasons f o r the apparent increasing incidence of mental i l l n e s s are l e s s e a s i l y discerned. In contemporary American s o c i e t y , c e r t a i n trends have been noted which r e f l e c t contradictions and s t r a i n s i n the s o c i a l system and are p o t e n t i a l l y able to contribute to emotional c o n f l i c t s i n the i n d i v i d u a l .  Whether these lead  i n e v i t a b l y to mental i l l n e s s , or to behavior so deviant that the person concerned may have to go to an i n s t i t u t i o n , has not been c l e a r l y demonstrated.  But from studies of  h o s p i t a l i z e d p a t i e n t s i t does seem c l e a r that under c e r t a i n conditions these c o n f l i c t s may lead to mental d i s o r d e r .  1  1 Landy, David, " C u l t u r a l Antecedents of Mental I l l n e s s i n the United States," The S o c i a l Service Review. December 1958» p. 350.  3 I n the American c u l t u r e , h i g h v a l u e i s p l a c e d on achievement, p r e s t i g e , work, money, and l e i s u r e .  E f f o r t t o a t t a i n these  d e s i r a b l e g o a l s i s o f t e n accompanied by c o n f l i c t s i n c e the g o a l s themselves contradictory.  and the means t o a c h i e v e them are o f t e n F a i l u r e t o r e a c h such v a l u e d g o a l s  fre-  q u e n t l y r e s u l t s i n i s o l a t i o n o f the i n d i v i d u a l , a sense inadequacy,  and l o s s o f s o c i a l and p e r s o n a l i d e n t i t y .  The age  s t a t u s and r o l e d e f i n i t i o n s f o r each sex  g r a d a t i o n are n o t c l e a r i n a f l u i d urban s o c i e t y .  and females  of  are t r e a t e d s i m i l a r l y up t o a c e r t a i n age  l a t e r have d i f f i c u l t y i n i d e n t i f i c a t i o n w i t h masculine feminine r o l e s .  S t a t u s i s g a i n e d more t h r o u g h  achievement t h a n by r e a c h i n g a s p e c i f i c age. i n d i v i d u a l who  and Males and and  scholastic Thus the  i s l e s s endowed i n t e l l e c t u a l l y , o r who  comes  from a f a m i l y atmosphere which does n o t encourage l e a r n i n g , d e v e l o p s f e e l i n g s o f inadequacy without expected  as he a t t a i n s added y e a r s  s c h o l a s t i c achievement.  Youth i s v a l u e d ,  and n e i t h e r sex f a c e s o l d age w i t h p l e a s u r e . are i n t e r e s t e d i n work, n o t f o r i t s own  Many Americans  sake, but as a means  o f a c q u i r i n g m a t e r i a l p o s s e s s i o n s which a f f o r d  social  p r e s t i g e , and f o r the p r e s t i g e a t t a c h e d t o c e r t a i n k i n d s o f o c c u p a t i o n s themselves. valent.  Conspicuous  consumption i s p r e -  Work i s viewed f r e q u e n t l y as a n e c e s s a r y  r a t h e r t h a n as an a c t i v i t y o f f e r i n g i t s own personal s a t i s f a c t i o n .  evil  reward i n  I n the r a c e f o r achievement,  4  competition i s high, and many must remain i n an " i n f e r i o r " s o c i a l stratum of s o c i e t y despite t h e i r higher s o c i a l aspirations. S o c i a l and personal i d e n t i f i c a t i o n i s also d i f f i c u l t f o r the "marginal" persons i n American s o c i e t y who, because of some r a c i a l , c l a s s , ethnic or other d i s t i n c t i o n , cannot gain access to one culture or achieve happiness i n the other.  Negroes, Jews, immigrants and  t h e i r c h i l d r e n , f o r a v a r i e t y of reasons may f i n d assimil a t i o n d i f f i c u l t and acceptance unattainable. A l l persons " i n t e r n a l i z e " the c u l t u r a l system i n which they are reared:  the morals, a t t i t u d e s , customs and  b e l i e f s transmitted i n family and community.  But con-  temporary c i v i l i z a t i o n i s passing through a p e r i o d of r e v o l u t i o n a r y change.  Old c u l t u r a l forms are d i s i n t e g r a t i n g  and new ones are emerging.  The process of i d e n t i f i c a t i o n  with c u l t u r a l values which are i n a state of f l u x can be very e l u s i v e , and the struggle has l e f t many i n d i v i d u a l s stranded with no inner guides f o r behavior.  David Riesman  and h i s associates, i n t h e i r study of the changing American character, argue that t r a d i t i o n a l patterns are no longer adequate i n a r a p i d l y changing world, and that middle c l a s s Americans, i n p a r t i c u l a r , are no longer guided by inner standards but according to the way others are  5 behaving.  1  There i s l i t t l e doubt that the absence of stable  i n t e r n a l i z e d standards and i d e a l s can contribute to i n d i v i dual confusion and emotional i n s t a b i l i t y .  In a d d i t i o n to  the c u l t u r a l stresses already mentioned, the c o n t r i b u t i o n to mental unrest of i n t e r n a t i o n a l tensions, f e a r of atomic warfare and threat of t o t a l a n n i h i l a t i o n , may r e a l l y be c a l l e d i n c a l c u l a b l e . Dr. Ackerman has summed up the modern p i c t u r e i n the following terms: With the implementation of present-day i n s i g h t s , i t i s c l e a r that the issues of mental health need to be examined i n two d i r e c t i o n s — from the outside inward; and from i n s i d e , outward. Three i n t e r r e l a t e d l e v e l s of phenomena are involved: the s o c i a l organization of the community, and the r e l a t e d interpersonal pattern; the processes of an i n d i v i d u a l ' s emotional i n t e g r a t i o n i n t o the group; and the h i s t o r y and development of i n d i v i d u a l pers o n a l i t y . The issue, therefore, i s not whether the i n d i v i d u a l should accommodate to society, or society to be reshaped to f i t the i n d i v i d u a l ; i t i s c l e a r that the two are interdependent, and that i f mental health i s to be advanced, there must be p a r a l l e l changes i n both.2 The combined approach to mental i l l n e s s suggested i n the above statement involves both i n d i v i d u a l adaptation to s o c i e t y and modification of the s o c i a l structure to the needs of the i n d i v i d u a l . In each d i r e c t i o n , the profession  1 Riesman, David, with Nathan Glazer and Reuel Denney, The Lonely Crowd. Doubleday and Company, Inc., New York,  1955.  2 Ackerman, Nathan W., M.D., "Mental Hygiene and S o c i a l Work, Today and Tomorrow," S o c i a l Casework, v o l . 36, No. 2 (February 1955)» p. 70. (Underlining added).  6 o f s o c i a l work can make a v a l i d c o n t r i b u t i o n t o i n d i v i d u a l and  n a t i o n a l mental  S o c i a l Work and The  health.  Mental  Illness  p r a c t i c e o f s o c i a l work has  i m p o r t a n t i n the p r e v e n t i o n and due  become i n c r e a s i n g l y  treatment o f mental i l l n e s s  t o the many advances i n the u n d e r s t a n d i n g o f mental  ness i n the p a s t f i f t e e n y e a r s .  Mental i l l n e s s i s no  ill-  longer  r e g a r d e d as a p u r e l y p s y c h i a t r i c c o n c e r n , s i n c e the  contri-  b u t i o n s o f the p s y c h o l o g i c a l ,  sciences  have emphasized the f a c t o r s i n the f o c u s has  s o c i a l and  s i g n i f i c a n c e of s o c i a l and  c o n f l i c t s to  s o c i a l r e l a t i o n s h i p s p l a y i n the  mental i l l n e s s ,  work has  recognition  etiology  of  and  t o a d e q u a t e l y meet  responsibilities.  Many o t h e r p r o f e s s i o n s  therapies  the  p e r f e c t t h e i r methods, s k i l l s  t e c h n i q u e s i n t r e a t i n g the m e n t a l l y i l l , t h e i r changing  As  s o c i a l workers must extend t h e i r knowledge  o f p s y c h o p a t h o l o g y , and  w i t h the  cultural  development o f mental d i s t u r b a n c e .  moved from i n t r a p s y c h i c  o f the p a r t  biological  o f c o u r s e are  treatment o f mental i l l n e s s and  also  some p r o v i d e  s p e c i f i c a l l y geared t o the m e n t a l l y i l l . i t s own  groupwork s k i l l s  Social  c o n t r i b u t i o n i n o f f e r i n g casework i n direct  t r e a t m e n t , and  concerned  i n also  t o a l l e v i a t e , through s o c i a l r e f o r m , s t r e s s e s  and attempting  i n the  physical  and  c u l t u r a l environment which impede h e a l t h y development  and  behavior.  7 In the  b r o a d e s t sense, a l l s o c i a l work p r a c t i c e  c a r r i e d on by the  t h r e e methods o f casework, groupwork  community o r g a n i z a t i o n  has  some r e l a t i o n t o mental i l l n e s s  s i n c e the p r o m o t i o n of human w e l f a r e may health.  Governmental and  provisions  f o r the  better  mental  v o l u n t a r y e f f o r t s t o meet income  maintenance, m e d i c a l c a r e , h o u s i n g and and  care and  recreational  protection  needs,  o f s p e c i a l groups  which have become r e c o g n i z e d as e s s e n t i a l community bilities  and  responsi-  i n i n d u s t r i a l s o c i e t y — a l l promote the mental  as  w e l l as the p h y s i c a l w e l l - b e i n g o f i n d i v i d u a l s , groups  and  communities. More d i r e c t l y r e l a t e d t o the problem o f mental i l l n e s s i s p s y c h i a t r i c s o c i a l work, which u n t i l  quite  r e c e n t l y has  to mentally  disturbed work has  been c o n f i n e d t o casework s e r v i c e s  p e r s o n s and been d e f i n e d  d i r e c t and  responsible  their families. as  Psychiatric social  " s o c i a l casework undertaken i n  cooperation with psychiatry,  practiced  i n h o s p i t a l s , c l i n i c s , or under p s y c h i a t r i c a u s p i c e s , w i t h the purpose o f h e l p i n g disturbances."  1  (1)  for patients  hospitals;  (2)  w i t h mental o r  emotional  P s y c h i a t r i c s o c i a l work t h u s d e f i n e d  passes four areas: services  patients  i n d i v i d u a l casework and i n p s y c h i a t r i c wards and  casework w i t h c h i l d r e n and  encom-  after-care i n mental  adolescents  1 F r i e d l a n d e r , W a l t e r A., I n t r o d u c t i o n t o S o c i a l W e l f a r e . P r e n t i c e - H a l l , I n c . , New York, 1955, p. 3 9 9 .  3 brought before juvenile courts and r e f e r r e d to c h i l d guidance c l i n i c s and  s o c i a l agencies f o r treatment and  (3) casework with adult patients and  adjustment;  i n mental hygiene c l i n i c s ;  (4) casework and groupwork with psychoneurotic  i n m i l i t a r y and veterans' h o s p i t a l s and c l i n i c s .  patients In recent  years, groupwork i s being used i n c r e a s i n g l y i n a l l of these settings.  1  As a r u l e , p r o f e s s i o n a l  requirements f o r employment  as p s y c h i a t r i c s o c i a l worker include studies  i n an accredited  two  years of graduate  school of s o c i a l work, and  completion of the master's degree.  The  the  second year of  graduate t r a i n i n g may  include  s p e c i a l i n s t r u c t i o n i n psychi-  a t r i c s o c i a l work and  supervised f i e l d work t r a i n i n g i n a  p s y c h i a t r i c s e t t i n g , or such t r a i n i n g may be given i n the ' 2 f i r s t year of employment i n a p s y c h i a t r i c s e t t i n g . The major areas of learning required  are a knowledge and under-  standing of normal human behavior, of psychopathology, of family i n t e r a c t i o n and community l i f e and t h e i r impact on the i n d i v i d u a l , of community resources and  s k i l l i n their  u t i l i z a t i o n , and of the helping r e l a t i o n s h i p and i t s management.  1 Friedlander,  op. c i t . . p. 399«  2 Knee, Ruth I r e l a n , "Psychiatric S o c i a l Work," S o c i a l Work Yearbook 1957. American Association of S o c i a l Workers, Hew York, 1957, p. 437.  9  The ill  s o c i a l worker's r o l e i n r e l a t i o n t o m e n t a l l y  p a t i e n t s has undergone c o n s i d e r a b l e change i n t h e l a s t  few y e a r s .  T r a d i t i o n a l l y t h e caseworker s e r v e d as a l i n k  between t h e p a t i e n t and t h e community, and attempted t o e s t a b l i s h a working r e l a t i o n s h i p w i t h t h e f a m i l y r a t h e r t h a n with the p a t i e n t .  S o c i a l workers u s i n g b o t h casework and  groupwork methods a r e now i n some s e t t i n g s c o n c e n t r a t i n g t h e i r e f f o r t s i n d i r e c t therapy with the p a t i e n t .  They a r e  meeting problems v e r y s i m i l a r t o those encountered  by t h e  p s y c h o t h e r a p i s t and are c u r r e n t l y h a v i n g d i f f i c u l t y i n d e f i n i n g t h e i r p a r t i c u l a r r o l e as member o f t h e t h e r a p e u t i c team.  R e c e n t l y , emphasis i s b e i n g p l a c e d on t h e s o c i a l  worker's f u n c t i o n i n r e h a b i l i t a t i n g t h e p a t i e n t when he r e t u r n s t o t h e community, which n e c e s s i t a t e s an i n i t i a l r e l a t i o n s h i p between worker and p a t i e n t p r i o r t o t h e l a t t e r ' s hospital discharge. Ruth Knee has summarized t h e approach used by s o c i a l workers i n mental h o s p i t a l s and c l i n i c s as f o l l o w s : : Modern p s y c h i a t r y sees t h e m e n t a l l y o r e m o t i o n a l l y i l l p a t i e n t as a human b e i n g i n t r i c a t e l y r e l a t e d t o h i s s o c i a l environment, p a r t i c u l a r l y h i s f a m i l y . He i s a t o t a l p e r s o n w i t h many needs and many s t r e n g t h s and i s n o t t o be r e g a r d e d as an i s o l a t e d specimen o f pathology. Treatment o f t h e s i c k i n d i v i d u a l i s accomplished through t h e team approach, w i t h each p r o f e s s i o n a l d i s c i p l i n e adding i t s s p e c i a l s k i l l s i n o r d e r t o meet h i s needs. The s o c i a l worker p l a y s a p a r t i c u l a r l y import a n t p a r t i n t h i s p l a n o f treatment b y p r o v i d i n g a l i n k between t h e h o s p i t a l and c l i n i c  10 and t h e community o f which i t i s a p a r t . The s o c i a l worker a l s o works d i r e c t l y w i t h the p a t i e n t i n h e l p i n g him m o b i l i z e h i s p e r s o n a l r e s o u r c e s i n h i s e f f o r t s toward recovery.1 The p r e s e n t s t u d y i s concerned w i t h the l a t t e r f u n c t i o n o f the s o c i a l w o r k e r — t h a t o f d i r e c t work w i t h the h o s p i t a l i z e d p a t i e n t t o h e l p him towards r e c o v e r y .  It i s this  function  which i s c h a n g i n g as s o c i a l work i t s e l f has changed i n r e c e n t y e a r s , and as the concept and t r e a t m e n t o f mental i l l n e s s has  altered.  C u r r e n t Terminology H i s t o r i c a l l y , the term mental i l l n e s s i s a f a i r l y r e c e n t one, used w i d e l y i n N o r t h America t o d a y t o d e s c r i b e v a r y i n g degrees o f mental and e m o t i o n a l a b n o r m a l i t y , r a n g i n g from m i l d t o v e r y s e v e r e , as r e f l e c t e d i n s l i g h t t o g r o s s deviant conduct. may  M e n t a l i l l n e s s i s a b r o a d concept which  i n c l u d e v e r y e f f i c i e n t members o f s o c i e t y as w e l l as  those committed t o mental i n s t i t u t i o n s as i n c a p a b l e o f managing t h e i r own  affairs.  C u r r e n t l y used i n t e r c h a n g e a b l y  i n p s y c h i a t r i c l i t e r a t u r e t o d e s c r i b e mental i l l n e s s , are the terms mental d i s o r d e r , mental c o n d i t i o n and mental disturbance.  Together w i t h the above terms, the term  p s y c h o s i s w i l l be used i n t h i s t h e s i s t o denote an a c u t e , severe mental d i s t u r b a n c e r e q u i r i n g h o s p i t a l t r e a t m e n t .  1 Knee, OP.  c i t . . p.  438  11 S c h i z o p h r e n i a i s one type o f p s y c h o s i s , and the s c h i z o p h r e n i c r e a c t i o n s comprise  the l a r g e s t g r o u p i n g o f the p s y c h o t i c  disorders. Mental i l l n e s s i s a s o c i a l i l l n e s s , e x a c e r b a t e d i f n o t caused by s o c i a l i n t e r a c t i o n .  I t s treatment cannot  be  c o n f i n e d t o i n s t i t u t i o n s , which c u r r e n t l y aim a t r a p i d r e d u c t i o n o f symptoms and prompt r e t u r n of the p a t i e n t t o the community. ill  The p r e v e n t i o n and a f t e r - c a r e o f the m e n t a l l y  i s a community, n o t h o s p i t a l , r e s p o n s i b i l i t y .  Prolonged  h o s p i t a l i z a t i o n i n most c a s e s i s n o t t h e r a p e u t i c a l l y sound, but c o n t r i b u t e s t o the s o c i a l d e t e r i o r a t i o n and dependency o f the p a t i e n t .  F o r t h i s r e a s o n the term  s o c i a l worker i s f a l l i n g i n t o d i s u s e .  "psychiatric"  A l l social  workers,  no m a t t e r i n what s e t t i n g t h e y work, w i l l encounter disturbance i n t h e i r c l i e n t e l e .  mental  I n c r e a s i n g l y they w i l l  be  e x p e c t e d t o t r e a t the p r e - p s y c h o t i c , and t o m a i n t a i n the improvement and p r e v e n t the r e l a p s e o f the c h r o n i c p s y c h o t i c , a f t e r h i s d i s c h a r g e from  hospital.  M e d i c a l p r a c t i t i o n e r s i n the community must share t h i s r e s p o n s i b i l i t y , and w i t h s o c i a l workers expand t h e i r knowledge o f p a t h o l o g i c a l symptoms, t h e i r d e r i v a t i o n treatment.  and  S o c i a l workers must i n c r e a s e t h e i r u n d e r s t a n d i n g  o f the onset and c o u r s e o f mental d i s o r d e r s so as t o p r e v e n t p r o g r e s s i v e d e t e r i o r a t i o n of the c o n d i t i o n t o the p o i n t where h o s p i t a l i z a t i o n becomes e s s e n t i a l .  They must a l s o  12 l e a r n to recognize  when p s y c h i a t r i c c o n s u l t a t i o n i s i n d i c a t e d  so t h a t the m e n t a l l y  i l l w i l l he r e f e r r e d as e a r l y as p o s -  s i b l e f o r treatment.  F i n a l l y t h e y must become more f a m i l i a r  w i t h the b e h a v i o r a l p a t t e r n o f the c h r o n i c p s y c h o t i c  who,  w i t h adequate s u p e r v i s i o n , can be m a i n t a i n e d o u t s i d e h o s p i t a l . I f s o c i a l workers are t o be work w i t h p s y c h o t i c s , p a t i e n t s who  and  effective in their  e s p e c i a l l y with  schizophrenic  comprise h a l f the p a t i e n t p o p u l a t i o n  h o s p i t a l s and who  o f mental  are i n c r e a s i n g l y b e i n g d i s c h a r g e d  community, i t i s i m p e r a t i v e  to  the  t h a t t h e y have adequate c l i n i c a l  knowledge o f mental d i s t u r b a n c e s ,  and  t h a t they u t i l i z e  the  c u r r e n t c o n c e p t s b e i n g d e v e l o p e d which are s u i t e d t o t r e a t ment of the m e n t a l l y Nature and  ill.  O r i g i n of Mental I l l n e s s Throughout the ages, the concept o f mental  has  been c o n s t a n t l y r e v i s e d , as man's u n d e r s t a n d i n g o f  human mind i n c r e a s e d , mental d i s t u r b a n c e  and new  developed.  mystical conception was  illness  t h e o r i e s as t o the cause o f I n the middle ages, a  of mental i l l n e s s p r e v a i l e d :  r e g a r d e d as demon-possession.  c l o s e o f the  18th  scientifically  century  I t was  o n l y towards the  s t u d i e d , w i t h the r e s u l t t h a t two  t h a t mental d i s o r d e r s were due others  t h a t the  madness  t h a t mental d i s o r d e r s were  emerged t o e x p l a i n the cause o f i n s a n i t y .  b r a i n , and  the  to organic  cause was  theories  Some b e l i e v e d changes i n the  psychological.  Both  13 t h e s e t h e o r i e s p e r s i s t today and mental c o n d i t i o n s a t  present  are d i v i d e d i n t o those t h a t are r e g a r d e d as f u n c t i o n a l , o r p s y c h o l o g i c a l l y caused, and organic,  those t h a t are c o n s i d e r e d  as  or p h y s i o l o g i c a l i n o r i g i n . A more h o l i s t i c approach t o the n a t u r e of mental  i l l n e s s g a i n e d acceptance due Meyer and are n o t  Sigmund F r e u d , who  an e x p r e s s i o n  mind o r body, but  o f any  t o the r e s e a r c h  of  Adolf  b e l i e v e d t h a t mental symptoms one  p a r t o f the  organism—  are r e a c t i o n s o f the whole  integrated  organism t o e n v i r o n m e n t a l s t r e s s e s .  Thus the n a t u r e  and  o r i g i n o f mental i l l n e s s can be u n d e r s t o o d o n l y  through  s t u d y o f the whole i n d i v i d u a l , h i s p e r s o n a l  racial  and  h i s t o r y , h i s environment, and h i s p h y s i c a l and  mental  structure• I t appears t h a t an e c l e c t i c , o r  "organismic"  theory  of c a u s a t i o n which u t i l i z e s the  i s now  a c c e p t e d by most l e a d i n g p s y c h i a t r i s t s .  Kolb  1  describe  i l l n e s s as  s e v e r a l views above Noyes  and  the c u r r e n t e t i o l o g i c a l concept of mental  follows: F o r the p r e s e n t , t h e r e f o r , i t seems most f r u i t f u l t o l o o k upon most mental d i s o r d e r s not as the r e s u l t o r e x p r e s s i o n o f some ' d i s e a s e ' but as a mode o f b e h a v i o r o r l i v i n g t h a t i s the l o g i c a l , a l t h o u g h s o c i a l l y  1 Noyes, A r t h u r P., M.D., and Lawrence C. K o l b , M.D., Modern C l i n i c a l P s y c h i a t r y . V. B. Saunders Co., P h i l a d e l p h i a , 1958, p. 83.  14 maladjusted, outcome of the p a r t i c u l a r i n d i v i d u a l ' s o r i g i n a l endowment, of the molding influences of the home, of traumatic experiences that modified p e r s o n a l i t y development, of the stresses and problems springing perhaps from deep within h i s emotional and i n s t i n c t i v e , l i f e , of h i s i n a b i l i t y to meet these s t r a i n s , of the type of self-defense reactions h a b i t u a l l y u t i l i z e d f o r minimizing anxiety, and of any b o d i l y ailments that may impair the i n t e g r i t y or e f f i c i e n c y of h i s b i o l o g i c a l organism. Mental disorders should therefor he regarded as patterns of human r e a c t i o n set i n motion by s t r e s s . In agreement with t h i s theory i s the u n i t a r y concept of mental i l l n e s s proposed by K a r l Menninger and h i s a s s o c i a t e s 1 who were dismayed by the multiple c l a s s i f i c a t i o n s  of mental d i s -  orders i n existence based upon symptomatology, rather than upon o r i g i n .  They contend that a l l mental i l l n e s s  e s s e n t i a l l y the same i n q u a l i t y : represent  quantitative  is  symptomatic types merely  differences.  In a d d i t i o n , everyone  has mental i l l n e s s of d i f f e r e n t degrees at d i f f e r e n t According to t h i s theory, mental i l l n e s s  times.  i s but one p o s i t i o n  i n a continuum or scale of well-being which measures the successfulness of an i n d i v i d u a l ' s adaptation or r e a c t i o n to h i s environment " . . . at one end of i t would he h e a l t h , happiness,  success, achievement and the l i k e and at the  other end misery, f a i l u r e ,  crime, d e l i r i u m , and so f o r t h . "  p  1 Menninger, K a r l , M . D . , with Henri E l l e n b e r g e r , M . D . , Paul Pruyser, P h . d . , and Martin Mayman, P h . d . , "The Unitary Concept of Mental I l l n e s s , " B u l l e t i n of the Menninger C l i n i c , v o l . 22, l o . 2 (March 1958), p . 10. 2 Ibid.  15 U s i n g such a s c a l e , an i n d i v i d u a l can he r e l a t i v e l y healthy;  classified  m i l d l y , r e l a t i v e l y or s e v e r e l y  By t h i s t h e o r y , the ego  as sick.  o r i n t e g r a t i n g component  o f the p e r s o n a l i t y , overcome "by a v a r i e t y o f s t r e s s e s w i t h i n and  w i t h o u t , makes p r o g r e s s i v e l y more v a l i a n t attempts  t o r e c o n c i l e t h e s e s t r e s s e s and  to achieve e q u i l i b r i u m .  symptoms o f mental i l l n e s s are thus not p a r t o f the  ego,  but  a " f a i l u r e " on  are r e g a r d e d as c o n s t r u c t i v e z a t i o n may  The  ones, even though d i s o r g a n i -  r e a s o n , the u n i t a r y concept emphasizes the and  For t h i s  essential unity  health., and mental i l l n e s s i s seen as  impairment i n s e l f - r e g u l a t i o n whereby c o m f o r t , growth are t e m p o r a r i l y  v i v a l a t the b e s t  "an  production  s u r r e n d e r e d f o r the sake o f  l e v e l p o s s i b l e , and  gency c o p i n g d e v i c e s  the  ego's e f f o r t s  o c c u r t o a m i l d o r v e r y severe degree.  of sickness  The  a n e c e s s a r y p r o t e c t i v e measure t o p r e -  v e n t complete p e r s o n a l i t y d i s o r g a n i z a t i o n .  and  from  which may  at the  be p a i n f u l . "  sur-  c o s t o f emer1  C l a s s i f i c a t i o n of Mental I l l n e s s S i n c e the  time o f H i p p o c r a t e s , e f f o r t s have been  made t o d i s t i n g u i s h v a r i o u s  t y p e s o f mental i l l n e s s .  Such  c l a s s i f i c a t i o n s were r e l a t e d t o the p r e v a i l i n g e t i o l o g i c a l concepts of mental d i s o r d e r s t h e o r y was  introduced.  An  1 Menninger, e t a l . , oo.  and  changex whenever a  new  enormous number o f p s y c h i a t r i c  c i t . . p.  11.  16  classifications  have been elaborated i n the course of the  c e n t u r i e s , becoming pr ogressivel y more complicated.  Until  r e c e n t l y most mental disorders were grouped according to the symptoms they produced.  With the acceptance of the modern  organismic theory, however, mental i l l n e s s has been categorized i n t o three basic groups according to the organic or psychogenic o r i g i n of the d i s o r d e r .  In 1952 the American  P s y c h i a t r i c A s s o c i a t i o n adopted the f o l l o w i n g c l a s s i f i c a t i o n of mental i l l n e s s . 1 I II  Ill  Disorders caused by or associated with impairment of b r a i n tissue f u n c t i o n . Disorders without c l e a r l y defined p h y s i c a l cause or s t r u c t u r a l change i n the b r a i n , but of psychogenic o r i g i n . Mental d e f i c i e n c i e s of f a m i l i a l o r i g i n , which have existed since b i r t h and are without demonstrated b r a i n disease or known prenatal cause.  This study i s not concerned with Groups I and III of the above c l a s s i f i c a t i o n ,  that i s , with acute and chronic b r a i n  disorders or with mental d e f i c i e n c y . but one category of Group I I ,  Its concern i s with  the schizophrenic r e a c t i o n s .  This second group i s a large one, since i t includes a l l reactions to psychological stresses—the psychoneuroses, psychosomatic d i s o r d e r s ,  the p e r s o n a l i t y d i s o r d e r s , and a  1 American P s y c h i a t r i c A s s o c i a t i o n , Diagnostic and S t a t i s t i c a l Manual of Mental Disorders. 1952.  the  17 major part of the psychotic r e a c t i o n s . reactions  The schizophrenic  comprise the greatest part of these  psychotic r e a c t i o n s ,  latter  as represented by actual numbers of  cases i n North American mental h o s p i t a l s  today.1  The Schizophrenic Reactions Defined A psychotic r e a c t i o n may be defined as "one i n which the p e r s o n a l i t y ,  in its  struggle f o r adjustment to  i n t e r n a l and external s t r e s s e s , u t i l i z e s severe disturbance,  affective  profound autism and withdrawal from r e a l i t y ,  and/or formation of delusions and h a l l u c i n a t i o n s . " The American P s y c h i a t r i c A s s o c i a t i o n c l a s s i f i e s the schizophrenic reactions  as one type of psychotic  dis-  order, and describes them as "fundamental disturbances r e a l i t y relationships ated a f f e c t i v e  in  and concept formations, with a s s o c i -  b e h a v i o r a l , and i n t e l l e c t u a l  disturbances,  marked by a tendency to r e t r e a t from r e a l i t y , by regressive trends, by b i z a r r e behavior, by disturbance  i n stream of  thought, and by formation of delusions and other evidence of the p r o j e c t i v e mechanism."^ In the continuum or scale of mental i l l n e s s , can be seen that schizophrenia i s a severe d i s o r d e r ,  it  since  1 Noyes and Kolb, op. c i t . . p . 391* 2 B r i t i s h Columbia P r o v i n c i a l Mental Health Services, P h y s i c i a n ' s Manual. 1956, Section 6, " D e f i n i t i o n of Terms." 3 Ibid.  18 i t r e s u l t s i n disturbances s h i p t o the o u t s i d e w o r l d  o f f e e l i n g , thought, and r e l a t i o n which p r e v e n t  the s c h i z o p h r e n i c  p e r s o n from making any normal adjustment t o h i s environment. The  s c h i z o p h r e n i c r e a c t i o n s have been d i v i d e d , by  the American P s y c h i a t r i c A s s o c i a t i o n , i n t o n i n e t y p e s , which are l a r g e l y d e s c r i p t i v e and based on the predominant symptoms displayed.  A l t h o u g h the c l i n i c a l d i a g n o s i s o f t h e v a r i o u s  d i s o r d e r s i s the r e s p o n s i b i l i t y o f t h e p s y c h i a t r i s t , and i s a v a i l a b l e t o the s o c i a l worker i n a p s y c h i a t r i c s e t t i n g , t h i s d i a g n o s i s i s u s e l e s s u n l e s s the caseworker c a n t r a n s l a t e the d i a g n o s t i c terms i n t o a m e a n i n g f u l p i c t u r e o f the p a t i e n t ' s p e r s o n a l i t y and b e h a v i o r a l p a t t e r n . reason,  Por t h i s  and because the caseworker w i l l v a r y h i s approach  depending on t h e d i a g n o s i s , t h e v a r i o u s t y p e s p h r e n i c r e a c t i o n s w i l l be d e f i n e d  of s c h i z o -  here.  The simple type i s c h a r a c t e r i z e d m a i n l y by an i n s i d i o u s and g r a d u a l r e d u c t i o n i n e x t e r n a l r e l a t i o n s h i p s and i n t e r e s t s . Emotions are l a c k i n g i n d e p t h , t h e r e i s a r e l a t i v e absence o f a c t i v i t y and p r o g r e s s i v e l y l e s s and l e s s use o f r e s o u r c e s . D e l u s i o n s and h a l l u c i n a t i o n s are r a r e l y e v i d e n t , b u t apathy and i n d i f f e r e n c e are conspicuous. The s e v e r i t y o f symptoms tend t o i n c r e a s e over l o n g p e r i o d s , u s u a l l y w i t h apparent mental d e t e r i o r a t i o n , i n c o n t r a s t t o the s c h i z o i d p e r s o n a l i t y , i n which t h e r e i s l i t t l e i f any change. The h e b e p h r e n i c type i s c h a r a c t e r i z e d m a i n l y by s h a l l o w , i n a p p r o p r i a t e a f f e c t i v e r e a c t i o n s , s i l l y behavior, f a l s e b e l i e f s (delusions), f a l s e perceptions ( h a l l u c i n a t i o n s ) , and r e t r e a t s t o s i m p l e r forms o f b e h a v i o r .  19 The c a t a t o n i c type i s c h a r a c t e r i z e d c h i e f l y by s t r i k i n g motor b e h a v i o r . This may be o f a marked i n h i b i t o r y k i n d , i n the f o r m o f s t u p o r , mutism, extreme compliance o r even t o t h e e x t e n t o f a seemingly v e g e t a t i v e e x i s t e n c e ; o r i t may c o n s i s t o f e x c e s s i v e motor a c t i v i t y and e x c i t e m e n t , g e n e r a l l y o f an i m p u l s i v e , u n p r e d i c t a b l e k i n d . The p a r a n o i d t y p e , u s u a l l y a r i s i n g l a t e r i n l i f e than the other types, i s c h a r a c t e r i z e d p r i m a r i l y by u n r e a l i s t i c , i l l o g i c a l t h i n k i n g , delusions of being persecuted or o f being a g r e a t p e r s o n , i d e a s o f r e f e r e n c e , and h a l l u c i nations. I t i s o f t e n c h a r a c t e r i z e d by unpred i c t a b l e b e h a v i o r , w i t h f a i r l y c o n s t a n t show o f a g g r e s s i o n and h o s t i l i t y . Excessive r e l i g i o s i t y may be p r e s e n t w i t h o r without persecutory delusions. The above major t y p e s o f the s c h i z o p h r e n i c r e a c t i o n s are n o t n e c e s s a r i l y m u t u a l l y e x c l u s i v e : m i x t u r e s are t o be found e s p e c i a l l y i n the e a r l y acute phases but a l s o i n some c h r o n i c p h a s e s . The acute u n d i f f e r e n t i a t e d type i n c l u d e s cases d i s p l a y i n g a wide v a r i e t y o f s c h i z o p h r e n i c symptoms, i n c l u d i n g c o n f u s i o n o f t h i n k i n g , and t u r m o i l o f emotion. F r e q u e n t l y c a s e s o f f i r s t or e a r l y a t t a c k s a r e grouped h e r e : later i f the r e a c t i o n p r o g r e s s e s i t w i l l c r y s t a l l i z e i n t o one o f the o t h e r d e f i n a b l e t y p e s . Symptoms c l a s s i f i e d i n t h i s c a t e g o r y appear a c u t e l y , o f t e n without apparent p r e c i p i t a t i n g s t r e s s , and a r e o f t e n accompanied by a pronounced s t a t e o f excitement o r d e p r e s s i o n . The symptoms o f t e n c l e a r i n a m a t t e r o f weeks but t e n d t o r e c u r . I n l a t e r c h r o n i c phases some p a t i e n t s may show few o f the o r i g i n a l symptoms o f t h e i r e a r l i e r phases and p r e s e n t an i n d e t e r m i n a t e symptom p i c t u r e . Such a r e c l a s s i f i e d as c h r o n i c nnfH f f f t r e n t i a t e d t y p e , which c a t e g o r y a l s o i n c l u d e s the s o - c a l l e d " l a t e n t " , " i n c i p i e n t " , and " p r e - p s y c h o t i c " s c h i z o p h r e n i c r e a c t i o n s , as w e l l as s c h i z o i d p e r s o n a l i t y t y p e s who d i s p l a y d e f i n i t e s c h i z o p h r e n i c thought, a f f e c t , and b e h a v i o r beyond s c h i z o i d t r a i t s . In a d d i t i o n t o m i x t u r e s w i t h i n s c h i z o p h r e n i a i t s e l f , t h e r e may be m i x t u r e s o f s c h i z o p h r e n i c symptoms w i t h those o f o t h e r  20 psychoses, notably with those of the manicdepressive group (or the a f f e c t i v e r e a c t i o n s ) . Such patients are o r d i n a r i l y r e f e r r e d to as the schizo-affective type. The mental content may be predominantly schizophrenia, with pronounced e l a t i o n ro depression. Or cases may show predominantly affective changes with schizophrenic-like t h i n k i n g or b i z a r r e behavior. Such l a t t e r cases u s u a l l y prove to be b a s i c a l l y schizophrenic i n nature. C l a s s i f i e d as the childhood type are those schizophrenic reactions occurring before puberty, such as psychotic reactions i n c h i l d r e n with autism as a predominant f e a t u r e . The term r e s i d u a l type i s applied to those p a t i e n t s who, a f t e r a d e f i n i t e schizophrenic r e a c t i o n , improve s u f f i c i e n t l y to he able to get along i n the community hut who continue to show recognizable r e s i d u a l disturbance of t h i n k i n g , a f f e c t i v i t y , and/or behavior.1 The implications f o r casework p r a c t i c e with the various types of schizophrenic reactions defined above w i l l be elaborated further on.  Obviously the caseworker must  vary h i s therapeutic techniques,  and h i s treatment goal and  p l a n , i n close accordance with these  differentiations.  Purpose, ffocus and Method of t h i s Study Successful  casework depends upon the caseworker's  knowledge of the problem to he t r e a t e d , casework methods of treatment—supportive and t h e i r accompanying techniques,  s k i l l i n using the and modifying—  s k i l l i n the  r e l a t i o n s h i p , and experience i n applying these  1 American P s y c h i a t r i c A s s o c i a t i o n , pp. c i t .  professional skills.  21 Beginning with the assumption that schizophrenia i s a disorder of psychogenic o r i g i n which i s "best treated "by psychological rather than p h y s i c a l therapy, the purpose of t h i s study i s to assess whether casework i s an appropriate treatment method f o r schizophrenia, and i f so, which method and techniques  are most e f f e c t i v e i n meeting the schizo-  phrenic' s s p e c i a l needs. The focus of t h i s study i s an attempt to answer the f o l l o w i n g questions.  What are the r o l e s of psychotherapy  and adjunctive p h y s i c a l therapies i n the current treatment of schizophrenia?:  Is casework a s u i t a b l e type of treatment  f o r the schizophrenic p a t i e n t , i n view of the nature and o r i g i n of schizophrenia?  What s p e c i a l q u a l i f i c a t i o n s does  the caseworker need i n order to act as t h e r a p i s t ?  Which  casework treatment method, supportive or modifying, i s most appropriate i n view o f the impairment i n ego functioning of the schizophrenic?  What i s meant by "ego breakdown" i n  schizophrenia, and how does i t contrast with ego functioning i n the normal, neurotic and sociopathic p e r s o n a l i t i e s ? What modification of casework i s necessary according to the d i f f e r e n t i a t i o n i n ego functioning among these various types of p e r s o n a l i t y ? In order to assess how the process of casework; study, s o c i a l diagnosis, planning and treatment, i s applied to the schizophrenic, the f o l l o w i n g questions w i l l be  22 considered.  What are the c e n t r a l problems of the schizo-  phrenic p a t i e n t ,  the strengths and weaknesses i n ego  functioning, and the defense mechanisms employed?  What are  the goals and focus of casework with the schizophrenic person i n view of the l i m i t a t i o n s imposed by h i s i l l n e s s ? How i s the treatment r e l a t i o n s h i p i n i t i a t e d , maintained and terminated, and what a t t i t u d e s and approaches should the caseworker employ i n t r e a t i n g the schizophrenic?  Finally,  how does the casework method d i f f e r from psychotherapy i n the treatment of  schizophrenia?  For t h i s study, a c r i t i c a l review and appraisal has been made of the orthopsychiatric l i t e r a t u r e  available  over the past decade on the psychopathology and treatment of schizophrenia. observations  From t h i s m a t e r i a l , and from the personal  and experience of the w r i t e r i n g i v i n g case-  work service to h o s p i t a l i z e d schizophrenic patients over a period of three years, an attempt w i l l be made to assess what i s meant by "ego breakdown" i n schizophrenia, and to contrast i t with ego functioning of the normal, neurotic and sociopathic p e r s o n a l i t i e s .  The c e n t r a l problems of  schizophrenia w i l l be defined; the strengths and weaknesses i n ego functioning and the defense mechanisms employed w i l l be assessed.  A c l i n i c a l p i c t u r e of schizophrenia, as seen  by modern p s y c h i a t r y , w i l l be given to provide the necessary t h e o r e t i c a l knowledge of t h i s  disorder.  23 F i n a l l y , an a n a l y s i s o f t h e casework p r o c e s s o f s t u d y , s o c i a l d i a g n o s i s , p l a n n i n g and implementing  treat-  ment, w i l l be made, as a p p l i e d t o t h e s p e c i f i c needs and problems  o f the schizophrenic p a t i e n t .  An attempt w i l l be  made t o s e l e c t which casework t r e a t m e n t method, s u p p o r t i v e or m o d i f y i n g , i s most a p p r o p r i a t e f o r h e l p i n g t h e s c h i z o p h r e n i c p a t i e n t , and which t e c h n i q u e s s h o u l d be employed. The g o a l s and f o c u s o f casework w i t h t h e s c h i z o p h r e n i c p a t i e n t w i l l he d e f i n e d , and t h e p r o f e s s i o n a l  relationship  between t h e caseworker and p a t i e n t examined t o determine the  a p p r o p r i a t e a t t i t u d e and approach t h e caseworker s h o u l d  use i n t r e a t m e n t .  The r e q u i r e m e n t s o f t h e caseworker  to act  as " t h e r a p i s t " w i l l be d e f i n e d , and a comparison made between casework and "psychotherapy." T h i s s t u d y i s concerned w i t h o n l y one a s p e c t o f casework treatment o f t h e s c h i z o p h r e n i c p a t i e n t , t h a t o f h e l p i n g t h e p a t i e n t a c h i e v e a b e t t e r s o c i a l adjustment, n o t on m o d i f i c a t i o n o f h i s environment needs and l i m i t a t i o n s .  t o meet h i s s p e c i f i c  I n a c t u a l p r a c t i c e , t h e two cannot  be s e p a r a t e d , b u t t h e approach o f t h i s s t u d y i s i n u s i n g the  p r i n c i p l e s o f "ego p s y c h o l o g y " t o enhance t h e p a t i e n t ' s  ego f u n c t i o n i n g t h r o u g h d i r e c t r e l a t i o n s h i p t r e a t m e n t .  CHAPTER II A CLINICAL PICTURE OE SCHIZOPHRENIA Schizophrenia i s a severely d i s a b l i n g emotional i l l n e s s which customarily r e s u l t s i n the p a t i e n t ' s withdrawal from other people, and i t u s u a l l y requires care.  hospital  I t may j u s t i f i a b l y be considered the most important  of the major psychoses f o r a number of reasons. Schizophrenia i s a chronic mental condition which may cause progressive d e t e r i o r a t i o n of the p e r s o n a l i t y even when i t s p e r i o d i c attacks are t r e a t e d .  In many cases  no r e a l improvement occurs a f t e r the i n i t i a l attack. cause of schizophrenia i s not c l e a r l y defined: no evidence of successful no proven cure e x i s t s .  there  The is  prevention of t h i s d i s o r d e r , and  Treatment i n the majority of cases  i s aimed at a l l e v i a t i n g behavioral symptoms and r e s o c i a l i zing the p a t i e n t ,  with no attempt at t r e a t i n g the under-  l y i n g pathology.  Schizophrenia i s d i f f i c u l t to t r e a t even  symptomatically and i t s prognosis except f o r i n d i v i d u a l attacks i s poor.  I t i s a condition which develops slowly  and i n s i d i o u s l y and often goes untreated u n t i l far progressed.  Schizophrenia i s so s o c i a l l y d i s a b l i n g that those  persons suffering from i t require prolonged or frequent  25 care i n a protective environment throughout t h e i r  lives.  I n c i d e n t a n d Age of Onset Schizophrenic patients constitute first  admissions to p u b l i c h o s p i t a l s  25 per cent of  f o r the mentally i l l .  Because of the r e l a t i v e youth at admittance and the r e l a t i v e l y long stay per patient  (an average of about 13 years  i n the United S t a t e s ) , the group of schizophrenias makes up approximately 50 per cent of the r e s i d u a l population of these h o s p i t a l s . 1  Noyes and Kolb state that 60 per cent  of the population of state h o s p i t a l s  w i l l u s u a l l y be made  up of schizophrenic patients because schizophrenia tends to be chronic and i n many instances does not shorten l i f e . They quote the age of onset of t h i s disorder as being from l a t e childhood to l a t e middle age,  although the most  quent age i s adolescence and e a r l y adult l i f e .  fre-  They also  consider that schizophrenia i s not as rare i n young c h i l d r e n as was formerly b e l i e v e d , although i t i s s t i l l uncommon. Gaw and h i s associates,^ using B l e u l e r ' s  p  funda-  mental signs i n making diagnoses, have concluded that schizophrenia i s much more common than i s generally thought.  1 B e l l a k , Leopold, M . D . , e d . , Schizophrenia; a Review of the Syndrome. Logos Press, New York, 1958, pp. 80-81. 2 Noyes and Kolb, Modern C l i n i c a l P s y c h i a t r y , pp. 390-391. 3 Gaw, Emir A . , M . D . , with Suzanne Reichard, P h . d . , and C a r l T i l l m a n , M . D . , "How Common i s Schizophrenia?" B u l l e t i n of the Menninger C l i n i c , v o l . 17 (1953)» p . 27.  26 They found the disorder present i n over 50 per cent of the out-patients examined i n t h e i r p r i v a t e p s y c h i a t r i c  clinic.  It e x i s t e d i n a continuum from s c h i z o i d p e r s o n a l i t y through pre-schizophrenia and ambulatory schizophrenia to  psychosis.  These authors suggest that the diagnosis "schizophrenia, with minimal, moderate and severe impairment, should be substituted  respectively"  f o r the terms r e f e r r e d to p r e v i o u s l y .  Relationship of Schizophrenia to S o c i a l Class One of the hypotheses tested by Hollingshead and R e d l i c h , i n t h e i r study of psychotic disorders p a t i e n t s , was whether the types of diagnosed  i n hospital  psychiatric  disorder were s i g n i f i c a n t l y connected to c l a s s  structure.  Underlying t h i s hypothesis was the assumption that  "indi-  v i d u a l l i v i n g i n a given c l a s s are subjected to problems of  l i v i n g that are expressed i n emotional and psychological  reactions  and disorders  different  i n quantity and q u a l i t y  from those expressed by persons i n other c l a s s e s . " 1 key  f i n d i n g i n t h i s study i s that i n psychotic  The  disorders  each type of r e a c t i o n shows " . . . a true linkage between c l a s s p o s i t i o n and the rate of treated c a s e s . . . .  The lower  p  the c l a s s , the higher the r a t e . "  I t was also found that  1 Ginsburg, S o l Wiener, " S p e c i a l Comment" (a review of S o c i a l Class and Mental I l l n e s s : A Com™-""•»*y Study, by August B. Hollingshead and F r e d r i c k C. R e d l i c h , published by John Wiley and Sons), American Journal of Orthopsychiatry, vol.  2 9 . No. 1 (January 1 9 5 9 ) , PP. 1 9 5 - 1 9 6 .  2 I b i d . . p. 197.  27  there was a much higher tendency f o r schizophrenia to occur i n lower c l a s s e s ; and f o r neuroses and somatic complaints to occur i n higher c l a s s e s . Marvin Opler, an anthropologist, notes that not only has schizophrenia increased, but that the symptoms displayed have changed with evolved c u l t u r a l patterns.  A  few decades ago schizophrenia was most commonly contained i n catatonic and hebephrenic symptoms:  today such reactions  are rare and found commonly only i n persons of poor educ a t i o n and i n some n o n l i t e r a t e c u l t u r e s .  He f i n d s psychoses  more prevalent i n r u r a l and non-sophisticated groups, and neuroses more common among urban and the more educated groups.1  Another author, Axelbrad, finds that lower classes  tend to use l e s s objective and more concrete t h i n k i n g and that " . . . i t seems reasonable to suppose t h a t , i f people who normally think i n these terms and who appear to have ego defects do become emotionally disturbed t h e i r w i l l be i n the d i r e c t i o n of psychoses,  disturbances  rather than neuroses,  since they w i l l not have as f u l l y developed i n t e l l e c t u a l p defenses." David Landy, i n t r a c i n g the c u l t u r a l and s o c i a l  1 Opler, American Journal of Orthopsychiatry, v o l . 25 (January 1 9 5 5 ) , PP« 51-54. 2 Axelbrad, S . , "Symposium: Progress i n Orthopsychiatry," American Journal of Orthopsychiatry, v o l . 2 5 (1955;, pp.  524-538.  28 forces at work which appear to hinder the process of human growth, ascribes the increase i n schizophrenia i n the United States to a combination of c u l t u r a l s t r a i n s : In a c u l t u r a l and h i s t o r i c a l epoch i n which r a p i d change seems to be the only constant f a c t of l i f e , i t i s not s u r p r i s i n g that one f i n d s so many patients whose schizophrenia i s perhaps best characterized by the question, •Who am I?' This need f o r , and lack o f , i d e n t i t y i s i n part a product of the psychol o g i c a l forces r e s u l t i n g from the quantity and nature of a f f e c t i n interpersonal r e l a t i o n s h i p s i n the home and i s t i e d to d i s t o r t i o n s and disease i n the i d e n t i f i c a t i o n process. I f the person does not have strong and p o s i t i v e parental or surrogate adult f i g u r e s with which to i d e n t i f y , h i s own i d e n t i t y may e a s i l y elude him. I f , i n addition, he i s the v i c t i m of psychological r e j e c t i o n , then he not only cannot e s t a b l i s h h i s i d e n t i t y , but he does not receive the necessary foundations of ego support and therefore i s hardly prepared even to attempt the search.1 Many i n v e s t i g a t i o n s have been made i n t o the s o c i a l and psychological background of the schizophrenic  patient,  and i t has been found with s i g n i f i c a n t frequency that schizophrenic persons have had unhappy childhoods i n emotionally unwholesome family s e t t i n g s .  To summarize,  schizophrenia occurs most frequently i n i n d i v i d u a l s who present  a background of s o c i a l and psychological i s o l a t i o n  from others, due to actual or perceived p h y s i c a l , i n t e l l e c t u a l or psychological inadequacies i n themselves, or  1 Landy, The S o c i a l Service Review. December 1958, p. 556.  29  r e j e c t i o n because of s o c i a l , other  class, religious,  r a c i a l or  barriers.1  E t i o l o g y of Schizophrenia Many theories have been put forward to explain the o r i g i n of schizophrenia, varying from anatomical and biochemical to p s y c h o l o g i c a l , from hereditary to environmental causes.  In accordance with the current unitary con-  cept of mental i l l n e s s , classification  and with the accepted standard  of the American P s y c h i a t r i c A s s o c i a t i o n ,  schizophrenia i s not a separate disease e n t i t y , but one p o s i t i o n i n a continuum ranging from mental health to severe mental sickness.  Its  o r i g i n i s considered to be psycho-  genic, since no other cause has been c o n c l u s i v e l y proved. Leading p s y c h i a t r i c a u t h o r i t i e s  also seem agreed that the  psychological causes of schizophrenia are multiple and often 2  i d e n t i c a l with those of a l l psychogenic mental However, no a u t h o r i t i e s that the s p e c i f i c out.  disorders.  on schizophrenia today w i l l claim  causes of t h i s i l l n e s s have been singled  They prefer to believe that schizophrenia i s but a  p a r t i c u l a r r e a c t i o n on the part of the i n d i v i d u a l to multiple stresses which i n another i n d i v i d u a l would r e s u l t i n a d i f ferent syndrome of mental 1 Noyes and Kolb, O P .  illness.  c i t . . pp. 390-31*  2 Menninger, et a l . , B u l l e t i n of the Menninger C l i n i c , v o l . 22, No. 2 (March 19581".  30  Since i t i s generally agreed that schizophrenia i s a r e a c t i o n to psychological s t r e s s e s , only the psychol o g i c a l and psychoanalytical theories as to the o r i g i n of schizophrenia w i l l he reviewed here.  H i s t o r i c a l l y , four  major theories have been the most prominent; those of Emil K r a e p e l i n , Eugen B l e u l e r , Adolf Meyer and Sigmund Freud. Kraenelin grouped together some widely d i s s i m i l a r conditions i n t o one large category, b e l i e v i n g the various symptoms were a l l d i f f e r e n t signs of a single disease process of p h y s i c a l origin.  He l a b e l l e d t h i s disease "dementia" (because these  conditions a l l seemed to have a malignant tendency and to tend towards d e t e r i o r a t i o n ) plus "praecox"  (because the  d e t e r i o r a t i o n seemed to begin e a r l y i n l i f e ) .  This pes-  s i m i s t i c view of dementia praecox as a degenerative, disease l a t e r proved u n j u s t i f i e d . 1  incurable  B l e u l e r . influenced by  Freud's t h e o r i e s , pointed out that the basic s i m i l a r i t y i n conditions of dementia praecox was not the tendency to "dement" nor the tendency for the disease to begin e a r l y i n l i f e , but rather " . . . c e r t a i n p e c u l i a r i t i e s which could best be described as a kind of s p l i t t i n g of mental functions,  a  disturbance of the processes of association and of the p  normal connections of the emotions with i d e a s . "  He coined  the name " s c h i z " ( s p l i t ) "phrenic" (mind) to describe the 1 Menninger, K a r l , M . D . , "The Diagnosis and Treatment of Schizophrenia," B u l l e t i n of the Menninger C l i n i c , v o l . 12, No. 3 (1948), p . 9 6 . 2 Ibid., p. 9 7 .  31  condition.  His i n t e n t i o n was to enlarge the scope of  "schizophrenia" to include non-psychotic and non-deterior a t i n g cases:  and he conceived of the symptoms as ranging  i n i n t e n s i t y a l l the way from the p a t h o l o g i c a l to the normal. Meyer was convinced that schizophrenia was the r e s u l t of an accumulation of habit disorganizations  resulting  from progressive maladaptations on the part of the i n d i v i d u a l to both p h y s i o l o g i c a l and psychological s t r e s s e s . d i d not l i m i t himself, as d i d Meyer, to the  Freud  interpretation  of the symptoms as f a u l t y patterns, but also uncovered t h e i r symbolic meaning.  He emphasized two aspects of schizo-  phrenia—the regressive and the r e s t i t u t i v e  symptoms.  The  former are seen as a r e t r e a t by the i n d i v i d u a l to the time when the ego had not as yet developed or had j u s t begun to develop.  They are expressed i n withdrawal from the environ-  ment, world destruction phantasies, and depersonalization. The r e s t i t u t i v e  symptoms are attempts to replace  the  e x i s t i n g world from which the patient has retreated by such phenomena as h a l l u c i n a t i o n s , delusions, phantasies or p e c u l i a r i t i e s  of language.  Freud's p o s i t i o n , modern psychoanalysis  world reconstruction In keeping with explains  schizo-  phrenia i n terms of psychological dynamics, with no cons i d e r a t i o n of somatic causes.  The views of the three p r e -  ceding authors have not been r e t a i n e d . 1  1 A r i e t i , S i l v a n o , M . D . , Interpretation of Schizophrenia. Robert Brunner, New York, 1955* pp. 19-27.  32  C a r l Jung was the f i r s t  author to conceive of the  p o s s i b i l i t y of a psychosomatic mechanism i n schizophrenia, and he attempted a d e s c r i p t i o n of the basic p e r s o n a l i t y of the schizophrenic which he i d e n t i f i e d with the i n t r o v e r t type.  Today i t i s well recognized that the i n t r o v e r t or  s c h i z o i d type of p e r s o n a l i t y i s more susceptible to developing a schizophrenic i l l n e s s than any other p e r s o n a l i t y type, and t h i s theory i s widely accepted. i n the s c h i z o i d p e r s o n a l i t y are: r e l a t i o n s with others;  Inherent t r a i t s  "avoidance of close  i n a b i l i t y to express d i r e c t l y  h o s t i l i t y or even ordinary aggressive f e e l i n g s ; thinking.  and a u t i s t i c  These q u a l i t i e s r e s u l t e a r l y i n coldness,  ness, emotional detachment, fearfulness,  aloof-  avoidance of com-  p e t i t i o n , and day dreams r e v o l v i n g around the need f o r omnipotence.  As c h i l d r e n , they are u s u a l l y q u i e t ,  obedient, s e n s i t i v e and r e t i r i n g .  shy,  At puberty, they f r e -  quently become more withdrawn, then manifesting the aggregate of p e r s o n a l i t y t r a i t s known as i n t r o v e r s i o n , namely, quietness, seclusiveness,  'shut-in-ness,'  and u n s o c i a b i l i t y ,  often with e c c e n t r i c i t y . " 1  The person who has a s c h i z o i d  p e r s o n a l i t y appears aloof,  detached, l e s s emotional, l e s s  concerned and l e s s i n v o l v e d .  He has learned to avoid  anxiety hy p h y s i c a l distance and hy repression.  Using these  neurotic defenses he may carry on h i s l i f e ; or e l s e , due  1 American P s y c h i a t r i c A s s o c i a t i o n , Diagnostic and S t a t i s t i c a l Manual of Mental Disorders. 1 9 5 2 .  33  to other f a c t o r s , may develop a schizophrenic break. schizoid personalities  show no mental abnormalities  the outbreak of a schizophrenic  Many before  illness.  Harry Stack S u l l i v a n demonstrated that schizophrenia i s engendered by poor interpersonal especially parent-child relations. contemporaries,  relations,  More than any of h i s  S u l l i v a n thought that the schizophrenic  could be treated by psychotherapy. 1  In h i s book,  Interpretation of Schizophrenia. Silvano A r i e t i has  explained  the o r i g i n and development of schizophrenia as due to psychol o g i c a l stresses imposed on the c h i l d by h i s i n t e r a c t i o n with the parents, e s p e c i a l l y the mother, which r e s u l t i n the c h i l d ' s developing a schizophrenic r e a c t i o n .  Arieti's  approach combines the theories of Freud, S u l l i v a n and Jung, and that of the recent psychoanalytical findings i n c h i l d development.  His psychological theory i s the most i n c l u s i v e  and e a s i l y understood, and i s widely accepted by p s y c h i a t r y , to explain the development of the schizophrenic process. His i n t e r p r e t a t i o n makes an excellent t h e o r e t i c a l framework f o r psychotherapy and casework with the schizophrenic patient. A x i e t i ' s Developmental Theory of Schizophrenia A r i e t i summarizes h i s conception of schizophrenia  1  A r i e t i , op. c i t . . pp.  27-39*  34 by s t a t i n g t h a t :  "schizophrenia i s a s p e c i f i c r e a c t i o n to  an extremely severe state of anxiety , originated i n c h i l d hood, r e a c t i v a t e d l a t e r i n l i f e . " 1  This type of r e a c t i o n  occurs when no other s o l u t i o n , no other p o s s i b i l i t y of adjustment,  i s any longer available to the p a t i e n t .  Prolonged childhood, a c h a r a c t e r i s t i c unique to the human r a c e ,  i s the basis of t h i s mental c o n d i t i o n .  The  newborn of many species are helpless and dependent on parental care f o r s u r v i v a l , needing food, r e s t , warmth, and contact with the mother's body to l i v e .  The human i n f a n t ,  however, has an a d d i t i o n a l need f o r s e c u r i t y , which can be gained only through parental love and approval.  The c h i l d  develops a system of what i s " r i g h t " and "wrong," what i s "good" and "bad," through the parents' or d i s a p p r o v a l . respectful  a t t i t u d e s of approval  I f the parents have a warm, l o v i n g ,  and sympathetic attitude toward the c h i l d , he  w i l l develop the same attitude toward himself and l a t e r on toward others. The c h i l d also learns to conceive h i s own r o l e i n l i f e according to the views of a l l the persons with whom he interacts.  The acceptance,  love and approval of others  b u i l d s both h i s own self-esteem, and h i s sense of s e l f identity.  Should the c h i l d he constantly surrounded,  1 Arieti, OP.  c i t . . p . 43.  35 however, by h o s t i l i t y and disparagement,  he cannot f e e l  secure and so becomes extremely anxious. which stimulates  Parental a f f e c t i o n  incestuous sexual f e e l i n g s  i n the c h i l d can  create anxiety, as may parental overprotection which i n h i b i t s self-realization,  " h o s t i l i t y " masked as concern, and an  inconsistent attitude on the part of the parents which confuses the c h i l d .  The anxious c h i l d w i l l r e s o r t to the use  of many defenses to protect himself from h i s intense f e e l i n g of being worthless, unwanted, and insecure.  One type of  defense i s repression, the removal from consciousness of many unpleasant experiences which occurred i n childhood. The b e l i e f s ,  attitudes  and generalizations which the c h i l d  unconsciously assumed on account of these experiences  will  also be retained i n the unconscious. The c h i l d l i v i n g continuously i n a destructive atmosphere may also develop the self-image child.  of being the bad  During the f i r s t year of l i f e , the c h i l d conceives  h i s mother as "good," because she met h i s p h y s i c a l and emotional needs at l e a s t f a i r l y adequately.  L a t e r , however,  the mother may resent the c h i l d ' s development of h i s own w i l l , and r e j e c t him subtly or openly.  Because of h i s  extreme dependency on h i s mother, the c h i l d t r i e s  desper-  a t e l y to r e t a i n the image of the "good mother" but i n many cases can do so only i f he b u i l d s at the same time an image of himself as a "bad c h i l d " who i s being r e j e c t e d because of h i s badness.  The good image of the parent can be  36 maintained only by repressing the unpleasant t r a i t s of the parent:  thus consciously the c h i l d has a good image, and  unconsciously, a bad image, of the disapproving parent. In a d d i t i o n to the organization of these conscious and unconscious images, and to the repression of many unpleasant experiences,  the c h i l d who i s r a i s e d i n an anxiety-  producing atmosphere develops r e l a t i v e l y f i x e d patterns of behavior i n h i s interpersonal r e l a t i o n s .  These  characteristic  means of gaining approval or avoiding disapproval (and hence anxiety) w i l l r e s u l t ,  according to Karen H o m e y , 1 i n the  development of three types of p e r s o n a l i t i e s  i n anxious  children—the compliant, the aggressive and the detached. Even though the c h i l d thinks he i s bad, he w i l l t r y cons t a n t l y to win h i s parents'  l o v e , using whatever method w i l l  win approval, or at l e a s t w i l l avoid d i s a p p r o v a l .  He may  submit to parental demands; he may f i g h t and argue to gain what he wants;  or he may withdraw p h y s i c a l l y and emotionally  from h i s parents as much as p o s s i b l e .  The c h i l d w i l l  to the method which he finds w i l l work best with h i s and which w i l l succeed i n reducing h i s own anxiety.  cling parents, Thus  the type of r e l a t i o n s h i p the c h i l d has with h i s parents w i l l determine the type of p e r s o n a l i t y and c h a r a c t e r i s t i c pattern he develops.  defense  l o r the c h i l d exposed to severe  1 Horney, Karen, The Neurotic P e r s o n a l i t y of our Time. Norton Press, New York, 1937.  37 anxiety, however, a d d i t i o n a l defenses are needed, and he w i l l develop neurotic symptoms of various k i n d s . Anxiety i n childhood i s the fundamental feature of the three p s y c h i a t r i c disorders—psychoneurosis, and psychopathic c o n d i t i o n s .  psychosis,  "However, from the h i s t o r y of  the childhood of schizophrenic p a t i e n t s ,  we l e a r n that i n  that p e r i o d of l i f e the anxiety of the patients was of such tremendous i n t e n s i t y , that no s u f f i c i e n t  self-esteem and  sense of s e l f - i d e n t i t y could be b u i l t and that c e r t a i n trends of psychological development p r e v a i l e d over  others."1  U s u a l l y i n the h i s t o r y of schizophrenia both parents have f a i l e d the c h i l d , often f o r d i f f e r e n t reasons. Frequently the combination i s as f o l l o w s :  a domineering,  nagging, h o s t i l e , overanxious, obsessive,  perfectionistic,  f r i g i d and psychosexually immature mother, who gives the c h i l d no chance to assert himself, i s married to a dependent, weak, passive man.  This i s a d e s c r i p t i o n of the  "schizophrenogenic" mother.  so-called  Very frequently the c h i l d of  such a union develops the character changes which are found i n the s c h i z o i d p e r s o n a l i t y .  The opposite combination of  parents also occurs but l e s s frequently:  a tyrannical  father i s married to a weak mother, who has solved her own p e r s o n a l i t y problems by u n c o n d i t i o n a l l y accepting her  1 A r i e t e , oo. c i t . . p . 52.  38 husband's r u l e s .  These r u l e s do not allow her to give  enough love to the c h i l d . A r i e t i emphasizes that the e a r l y interpersonal r e l a t i o n s h i p of the c h i l d with the mother i s the most s i g n i f i c a n t f a c t o r f o r the development of schizophrenic i l l n e s s . At times, because of war, separation, death, d i v o r c e , and so on, the c h i l d i s l e f t almost t o t a l l y i n the hands of the destructive parent, the mother.  In a l l cases, however, an  intense r e l a t i o n s h i p e x i s t s f i r s t between the preschizophrenic c h i l d and h i s parents, e s p e c i a l l y the mother, before the defenses c h a r a c t e r i s t i c of schizophrenia appear. intense relatedness  This  i s destructive to the c h i l d and provokes  enormous anxiety, so that he i s almost overwhelmed by h i s feelings.  The mother's h o s t i l i t y creates objectionable  behavior i n the insecure c h i l d :  her g u i l t over her h o s t i l i t y  increases her anxiety, which i n turn i s sensed by the c h i l d with the r e s u l t that he acts even more adversely.  A cir-  c u l a r process thus originates which can assume enormous proportions and have a far-reaching and grossly d i s a b l i n g effect  on the c h i l d . Because of the intense experience with h i s parents,  u s u a l l y from the end of the f i r s t to the end of the year of l i f e ,  fifth  the preschizophrenic c h i l d finds i t very  d i f f i c u l t to organize the defenses o r d i n a r i l y developed hy the anxious c h i l d .  Instead he i s forced i n t o a pattern which  39 i s often the forerunner of schizophrenia.  O r d i n a r i l y the  anxious c h i l d can maintain a p i c t u r e of h i s parents as  good,  "being helped by the parents who also t r y to create t h i s picture.  Simultaneously,  the c h i l d sees himself  as bad, which i s at l e a s t a stable self-image.  consistently In a d d i t i o n ,  the c h i l d i s able to t r a n s f e r the t r u s t he has i n h i s good parents to the world around him to some degree.  Should he  f a i l l a t e r on to correct both the image of himself and h i s parents i n a more r e a l i s t i c c e r t a i n circumstances,  f a s h i o n , he w i l l tend, under  to develop a neurosis or a socio-  pathic c o n d i t i o n . The p i c t u r e f o r the preschizophrenic c h i l d , however, i s quite d i f f e r e n t .  In the majority of cases, the mother's  r e j e c t i o n i s so obvious that the c h i l d cannot maintain the image of the good mother, formed i n h i s f i r s t d i d love and care f o r him.  year when she  He may regress to babyhood i n  h i s e f f o r t s to recapture t h i s secure f e e l i n g , b e l i e v i n g h i s only f a u l t was to grow towards independency.  In rare cases,  the c h i l d has no good parental image to t r y to r e t a i n , because he f e e l s he was r e j e c t e d from the beginning. c h i l d r e n f e e l u t t e r l y hopeless, and constitute  Such  the few who  develop e a r l y i n f a n t i l e autism and childhood schizophrenia. Never having been loved, they have developed no i n i t i a l t r u s t i n the mother (and hence i n others) to permit them to mature f u r t h e r ,  s o c i a l l y and emotionally.  The majority of  preschizophrenic c h i l d r e n , however, do make e f f o r t s  to  40 r e t a i n the o r i g i n a l good parental image, hut f a i l due to the parents'  continued h o s t i l i t y .  Unable to gain parental love  and approval, these c h i l d r e n attempt to reduce t h e i r anxiety i n two ways:  one leads to formation of the s c h i z o i d  p e r s o n a l i t y ; the other to the development of what A r i e t i terms the "stormy" p e r s o n a l i t y . Although he represses t h e i r worst  characteristics,  the preschizophrenic c h i l d i s u s u a l l y consciously aware that h i s parents are d e s t r u c t i v e . parents'  Such r e c o g n i t i o n of the  "badness," however, does not prevent the c h i l d  from developing a self-image of the "bad c h i l d . "  He cannot  blame the parents e n t i r e l y f o r t h e i r h o s t i l i t y , since he also harbors h o s t i l e thoughts toward them f o r t h e i r n e g l e c t . The c h i l d f e e l s g u i l t y because he believes he should love the parents who are w i l l i n g to give him p h y s i c a l care.  Por  t h i s reason he believes that although the parents are bad, he, the c h i l d , i s worse. extent,  The c h i l d i s w i l l i n g , to a c e r t a i n  to accept the bad parent, but t r i e s at the same time  to detach himself emotionally from the "badness" of the parent.  He expects constant parental disapproval and t r i e s  to avoid i t by reducing contact with the parent.  By  detaching himself emotionally, he w i l l avoid further attacks on h i s self-esteem.  Thus very often such a c h i l d  develops a s c h i z o i d type of p e r s o n a l i t y . repress h i s f e e l i n g s ;  He t r i e s  to  he becomes aloof and emotionally  41 flattened.  Such a c h i l d has learned that neither compliance  nor aggression w i l l b r i n g the acceptance he craves from h i s parents:  h i s only defense i s to withdraw from people. In some patients the s i t u a t i o n i s even more complicated. The attitude of the parent i s so inconsistent and the conscious parental image i s so frequently v a c i l l a t i n g between being the bad or the good one, that the c h i l d cannot even develop the self-image of the bad c h i l d , as at l e a s t something s o l i d and sure i n h i s l i f e , even i f negative. He suspects that he i s bad, but he i s not absolutely sure. He w i l l be i n a state of anxious uncertainty and w i l l develop an image of himself which, for lack of a better expression, may be c a l l e d the image of the presumably-bad-child. This image w i l l predispose him to a p a r t i c u l a r type of prepsychotic^personality, namely, the stormy personality.  This type of p e r s o n a l i t y shows a wider range of defenses than does the s c h i z o i d type.  Such a person alternates  between extreme submissiveness, h o s t i l i t y and detachment, but finds that none of these approaches to people his d i f f i c u l t i e s .  eliminates  This uncertainty about the way to react  i s enhanced by the inconsistency of the parents.  Thus, the  e a r l y environment promotes i n the c h i l d a capacity to change h i s a t t i t u d e s toward l i f e repeatedly:  such changes may be  slow or abrupt, and are often sudden, v i o l e n t and extreme. The self-image developed i n the stormy p e r s o n a l i t y i s even l e s s stable than i n the s c h i z o i d type, who f e e l s at l e a s t  1 A r i e t i , op. c i t . , p . 56.  42 c o n s i s t e n t l y unwanted.  The person with a stormy p e r s o n a l i t y  i s constantly and a c t i v e l y seeking f o r approval: reassured only temporarily hy p r a i s e ,  he i s  becoming even grandiose  and paranoidal when i n a good mood; the s l i g h t e s t sign of non-acceptance, however, makes him f e e l detested and hated. He f e e l s more i n t e n s e l y than does the s c h i z o i d , but does not enjoy the l a t t e r ' s p r o t e c t i o n from being hurt through emotional detachment* Usually the preschizophrenic c h i l d i s hopeful that when he grows up he w i l l gain the love deprived him i n childhood.  His abnormal pattern of r e l a t i n g to people, how-  ever, e i t h e r by emotional detachment or overanxious of approval, prevents t h i s f u l f i l l m e n t .  seeking  The lack of warm  s o c i a l r e l a t i o n s h i p s induces i n these c h i l d r e n a r i c h fantasy l i f e , through which they attempt to meet t h e i r need f o r a t t e n t i o n and a f f e c t i o n .  I t creates, too, an exaggerated  f e e l i n g of omnipotence i n the c h i l d : . . . . The normal c h i l d has feelings of omnipotence and l i v e s i n a world which he thinks e x i s t s f o r him only; but whereas a c h i l d who has normal r e l a t i o n s with h i s parents i s gradually corrected by them with t h e i r approach to r e a l i t y , because he wants to accept t h e i r r e a l i t y , the preschizophrenic c h i l d cannot depend on h i s parents f o r t h i s c o r r e c t i o n . The r e a l i t y which they show him, the r e a l i t y of the world, i s t h e i r unpleasant reality. The c h i l d i s reluctant to lose these f e e l i n g s of omnipotence; when he succeeds i n l o s i n g them, to a more or l e s s conscious degree he s t i l l has the desire to go hack to them. Together with t h i s tendency toward a f e e l i n g of omnipotence, there i s the tendency  43 toward a unique, or very subjective outlook. The c h i l d has tendencies to use h i s own language, with expressions he has coined. A l l these tendencies, which are c a l l e d a u t i s t i c , are more or l e s s suppressed and repressed but w i l l become conscious again during the p s y c h o s i s . . . . ! In a d d i t i o n to t h i s f e e l i n g of omnipotence, the preschizophrenic c h i l d tends to brood about h i s own sex identity.  He i s even more uncertain as to h i s sex than i s  the normal c h i l d , often because r e j e c t i o n by both parents prevents i d e n t i f i c a t i o n with e i t h e r one.  The c h i l d may also  f e e l that whether or not he i s male or female, h i s parents wanted a c h i l d of the opposite  sex.  A r i e t i considers the  Oedipus complex does not cause the anxiety found i n the preschizophrenic c h i l d .  I t i s hopelessness about obtaining  parental love and not fear of c a s t r a t i o n which i s most often at the root of the c h i l d ' s anxiety. Many schizoids avoid developing a psychosis by l i v i n g a l o n e l y , r e s t r i c t e d l i f e which prevents any close involvement with people.  In spite of t h e i r detachment,  however, schizoids do encounter episodes which cause sudden v i o l e n t i n j u r y to t h e i r self-esteem and tremendous i n anxiety;  such as marriage with i t s  increase  accompanying intimacy,  friendship with a person of the same sex which arouses latent homosexual wishes, and c h i l d b i r t h which arouses  1 A r i e t i , oo. c i t . . p . 60.  44 fear that the s c h i z o i d i s not good enough to he a mother. B l e u l e r declared that no schizophrenic should marry or have c h i l d r e n , so common i s the post-partum p s y c h o s i s . 1 though schizoids have repressed t h e i r f e e l i n g s  Even  to an enormous  degree, there s t i l l e x i s t s the desire f o r l o v e , warmth and closeness to others which may lead them into which they cannot  situations  tolerate.  The stormy p e r s o n a l i t y , who i s more eager to approach others, tends to develop schizophrenia more f r e quently than the well-defended s c h i z o i d .  He i s  repeatedly  hurt hy the r e f u s a l of others to meet h i s excessive need for a f f e c t i o n .  He also has more d i f f i c u l t y i n f i n d i n g h i s  r o l e i n the family and community, and e s p e c i a l l y i n adolescence i s very confused as to how to cope with h i s enlarging c i r c l e of l i f e .  He does not deny that love e x i s t s somewhere  as does the s c h i z o i d , and t r i e s f r a n t i c a l l y to f i n d  it.  Even i n the face of repeated f a i l u r e s he does not give up, u n t i l f i n a l l y h i s defenses collapse when he discovers h i s approaches are f u t i l e to gain what he wants.  all  The stormy  type i s s t i l l more r e s i l i e n t than the s c h i z o i d who becomes psychotic:  h i s attacks are generally shorter hut he w i l l  show more h o s t i l i t y and defiance, r e s i s t treatment and be more d i f f i c u l t to manage i n h o s p i t a l .  1 B l e u l e r , Eugene, Dementia Praecox or the Group of Schizophrenias. International U n i v e r s i t i e s Press, New York, 1950, p . 472.  45 Once the defenses of both the s c h i z o i d and stormyp e r s o n a l i t y types do break down, entering the psychosis offers  many advantages.  The patient no longer f e e l s  he i s the v i c t i m of h i s own inadequacy and  that  worthlessness,  but the v i c t i m of the malevolent doing of other people.  By  d i s p l a c i n g t h i s "badness" to others, the patient regains h i s self-esteem, and eliminates the self-image of the "bad child."  Increased d e s o c i a l i z a t i o n by the s c h i z o i d as he  moves gradually i n t o the psychosis,  reduces the anxiety  and h o s t i l i t y he always f e l t when i n contact with people. The i n d i v i d u a l i t y which the patient f e l t was crushed by others can f i n a l l y emerge since he no longer f e e l s g u i l t y and r e j e c t e d .  The psychosis i s the p a t i e n t ' s  to solve h i s d i f f i c u l t i e s . possible  last  attempt  "The patient has done everything  to defend himself, and everything has f a i l e d .  The  s c h i z o i d p e r s o n a l i t y no longer protects him; the stormy p e r s o n a l i t y produces another c r i s i s from which he cannot resurge.  He cannot compromise with r e a l i t y any more; now  he has to change ' r e a l i t y . '  He w i l l do so by entering the  psychosis.1,1 Onset and E a r l y Symptoms of Schizophrenia Schizophrenia i s u s u a l l y i n s i d i o u s i n onset although r e l a t i v e s  often i n s i s t i t was acute, not appreci-  ating the s i g n i f i c a n c e of the gradual p e r s o n a l i t y change  1 Arieti, OP.  c i t . . p . 80  46  which preceded the acute attack.  Even the s o - c a l l e d  "early"  cases admitted f o r treatment have been i l l f o r a considerable period p r i o r to h o s p i t a l i z a t i o n .  There seems to he no abrupt  t r a n s i t i o n from the s c h i z o i d type of p e r s o n a l i t y to the manif e s t psychosis.  In more than h a l f the cases there are  character anomalies,  such as s e c l u s i o n , withdrawal and  i r r i t a b i l i t y , which are r e a l l y the f i r s t disorder. phrenia:  early  symptoms of the  Any symptoms may be the i n i t i a l sign of schizoaside from the character abnormalities,  hysterical  and neurotic symptoms are the most common precursors. Patients may struggle against the disorder of schizophrenia f o r years before becoming emotionally "paralyzed" or " f l a t t e n e d "  or developing h a l l u c i n a t i o n s .  Delusions w i l l e x i s t f o r long periods, however, before being recognized as such.  Before the i n i t i a l attack, there may be  d i s t u r b i n g dreams which keep haunting the patient during waking hours.  Obsessive and compulsive ideas may precede  a l l other symptoms by many years.  A f f e c t u a l symptoms, such  as indifference and apathy, may dominate from the s t a r t , and chronic and acute depressions are the most common of a l l the symptoms of onset.  Catatonic symptoms are the most obvious  ones, and paranoid symptoms the most e a s i l y  concealed.1  1 K l i n e , Nathan S . , M . D . , Synopsis of Eugen B l e u l e r ' s Dementia Praecox or the Group of Schizophrenias. International U n i v e r s i t i e s Press, I n c . , New York, 1 9 5 7 ,  pp.  28-29.  47 Prognosis of the Schizophrenic Reactions The s o c i a l worker should he not only f a m i l i a r with the e a r l y symptoms displayed at the onset of schizophrenia i n order that treatment can begin as soon as poss i b l e , but also with the known facts about the outcome of t h i s d i s o r d e r , so that p r a c t i c a l treatment goals can be For centuries,  set.  schizophrenia was considered to be  i n c u r a b l e , and patients were committed to h o s p i t a l s marily f o r c u s t o d i a l care.  pri-  Beginning i n the 1930's, how-  ever, the outlook i n t r e a t i n g t h i s disorder became more o p t i m i s t i c with the i n t r o d u c t i o n of new b i o l o g i c a l  approaches.  These treatment methods included, i n chronological order of development:  a series of comas induced by i n s u l i n ; a series  of a r t i f i c i a l convulsions induced e i t h e r chemically or e l e c t r i c a l l y ; s u r g i c a l d i v i s i o n of c e r t a i n t r a c t s i n the brain ( i . e . ,  p r e f r o n t a l lobotomy) f o r the most advanced  cases of long standing; and the use of a group of chemical compounds commonly known as  tranquilizers.1  Recognition of the importance of psychological treatment methods became widespread while the b i o l o g i c a l approaches were developing. and acceptance;  I n d i v i d u a l i z e d personal care  psychotherapy; occupational therapy; the  stimulus of work; the s o - c a l l e d "therapeutic community" i n  1 White, The Abnormal P e r s o n a l i t y , pp. 549-559*  48 which, a l l f a c i l i t i e s  of the h o s p i t a l are oriented toward  treatment of the patient as an i n d i v i d u a l ; and the extension of the concept of the removal of r e s t r a i n t s  to the e l i m i -  nation of locked d o o r s — a l l these, although dating t h e i r o r i g i n to e a r l i e r p e r i o d s , received general acceptance.  In  many cases, what seems most important i s to provide the patient with an environment i n which he i s protected and i n which he can gradually work through h i s periods of confusion and disturbance away from the upsetting influence of h i s ordinary environment. 1 With these modes of treatment, the prognosis f o r schizophrenic reactions became d e f i n i t e l y more hopeful. 2 Menninger  reports that " . . . schizophrenia has a f a r  prognosis than carcinoma:  better  only a small percentage of  schizophrenics get i n t o h o s p i t a l s  • . . and many patients  remain i l l because they are p e s s i m i s t i c a l l y t r e a t e d , and hence n e g l e c t e d . "  He supports the view of t h i s disorder  as beginning i n e a r l y infancy, with gradual withdrawal and b u i l d i n g of defenses against s o c i a l r e l a t i o n s h i p s ;  the  gradual onset of symptoms, often p h y s i c a l , or a sudden acute attack, his  d i s p l a y i n g the presence of the i l l n e s s .  Gaw and  associates^ consider that the prognosis f o r schizophrenia  1 White, oo. c i t . . pp. 549-559. 2 Menninger, on. c i t . . p . 106.  3 Gaw, et a l . , op. c i t . . p . 28.  49 i s more hopeful than i s u s u a l l y thought to be since very few of t h e i r out-patients  justified,  diagnosed as having  t h i s disorder have been h o s p i t a l i z e d , or have committed suicide.  On the other hand, they recommend that one  should be conservative about the success of treatment of schizophrenia, and advise a " r e a l i t y oriented" approach, rather than "depth" psychotherapy, as the treatment of choice. The success of treatment seems d e f i n i t e l y to vary with the stage of the disorder at which i t i s introduced. I f the i l l n e s s has been permitted to go on f o r a long time, successful  treatment i s more d i f f i c u l t to o b t a i n .  from e a r l y treatment,  Aside  among other signs that have been  found r e l a t e d to good outcome are:  acute,  a confused, excited kind of disturbance;  sudden onset of  absence of schizo-  phrenic h i s t o r y i n the family; presence of an admixture of symptoms u s u a l l y found i n manic-depressive psychosis,  and  presence of some f a i r l y c l e a r psychological c o n f l i c t which p r e c i p i t a t e d the  disturbanee.1  In assessing the degree of d e t e r i o r a t i o n which accompanies t h i s disorder, and the p o s s i b i l i t i e s p Bleuler  of a cure,  states that schizophrenia as such r a r e l y leads to  death; but m o r t a l i t y , i n d i r e c t l y caused by t h i s 1 Noyes and Kolb, op. c i t . , pp. 416-419. 2 K l i n e , oo. c i t . . pp. 29-30.  disorder,  50 i s more frequent.  Seldom i s there evidence of a f u l l ,  complete r e c t i f i c a t i o n of delusional symptoms, so that the term "far-reaching improvement" should he used rather than "cure."  In h i s opinion, a l l schizophrenics upon release  show d i s t i n c t signs of t h e i r i l l n e s s , are not hard to f i n d . that i s ,  and these symptoms  In assessing the " p r a c t i c a l cure"—  the s o c i a l r e s t i t u t i o n of the p a t i e n t , there are  factors beyond the p a t i e n t ' s  c o n t r o l which affect  prognosis:  whether the employment f o r which the patient i s trained w i l l s t i l l he possible with h i s r e s i d u a l psychic s c a r r i n g ; and how s e n s i t i v e  and cooperative are the p a t i e n t ' s  relatives.  The support and i n t e r e s t of h i s family and employment i n a satisfying  job are the best i n d i c a t o r s of the  ultimate prognosis.  patient's  B l e u l e r defines the degree of d e t e r i o -  r a t i o n l e f t by a schizophrenic attack as " m i l d , " i f the patient i s capable of supporting himself outside  hospital;  " s e v e r e , " i f he i s completely incapable of s o c i a l  living;  and "medium," i f he i s between these two degrees.  Intel-  l e c t u a l i n s i g h t i s no sign of cure since i t i s only a part of the psyche which understands what i s going on, and since i t does not influence the emotional l i f e of the p a t i e n t . Statistical  evaluations of prognosis  are deceptive  since only h o s p i t a l i z e d schizophrenics are u s u a l l y assessed and since the conditions of admission and discharge vary with each h o s p i t a l .  B l e u l e r found that paranoids have the  51  best prognosis,  since t h e i r delusional system i s well  systematized and encroaches l e s s on the r e s t of the personality.  Hebephrenics have a r e l a t i v e l y poor prognosis  since t h i s r e a c t i o n occurs at an age when the i n d i v i d u a l has not f u l l y developed h i s s o c i a l c a p a c i t i e s i s less l i k e l y .  so employment  The prognosis f o r the simple schizophrenic,  who c h a r a c t e r i s t i c a l l y l i v e s a wandering, "hobo" type existence,  i s poor f o r the same reason.  The prognosis  for  a catatonic attack i s good, as the severe symptoms u s u a l l y c l e a r up spontaneously,  or respond to treatment q u i c k l y .  The outcome f o r the chronic undifferentiated type i s uncert a i n , although u s u a l l y the patient can be returned to the l e v e l of functioning which existed p r i o r to h i s attack. Gradual d e t e r i o r a t i o n i n s o c i a l functioning u s u a l l y accompanies t h i s type of r e a c t i o n , over a period of time. Men are more i n c l i n e d to develop paranoid symptoms than women, but there i s not much difference i n prognosis between men and women suffering from the various  types.  Acute attacks customarily r e s u l t i n only a mild degree of d e t e r i o r a t i o n , perhaps because they demand h o s p i t a l i z a t i o n and hence e a r l i e r treatment.  P h y s i c a l c o n d i t i o n , alcoholism,  degree of i n t e l l i g e n c e , and whether the attack was p r e c i p i tated by p h y s i c a l or psychic causes:  these f a c t o r s seem to  have no bearing on prognosis. In general, a l l types of schizophrenic reactions  52 w i l l respond to modern treatment methods.  I f each attack  i s promptly t r e a t e d , d e t e r i o r a t i o n can he prevented. Follow-up treatment reduces the p o s s i b i l i t y of relapse, prolongs the i n t e r i m period between a t t a c k s .  or  Seldom can  the l e v e l of s o c i a l functioning be r a i s e d above that which preceded the i n i t i a l attack, however; thus the best prognosis i s given those patients who functioned w e l l h o s p i t a l before t h e i r f i r s t  outside  admission, and who could support  themselves and s o c i a l i z e d f a i r l y adequately with other people. Evaluation of Treatment Methods f o r Schizophrenia There i s considerable controversy today as to the treatment of choice f o r schizophrenia.  Authors l i k e A r i e t i ,  Eromm-Eeichmann, Sechehaye, Menninger and Manfred B l e u l e r agree that psychotherapy i s the preferred treatment f o r t h i s disorder.  Psychotherapy aims at the removal of the patho-  genic cause as well as the i l l effects of the disorder and tends to strengthen the constructive parts of the p e r s o n a l i t y against the psycho-pathological process. The usefulness  of the p h y s i c a l forms of treatment  as an adjunct to psychotherapy i s well summarized by A r i e t i i n the f o l l o w i n g statement. 1  "The p h y s i c a l treatments  ...  reach only one of the desirable aims, although a very important one:  the removal of symptoms.  These treatments  1 A r i e t i , I n t e r p r e t a t i o n of Schizophrenia, p . 481.  53 axe therefor symptomatic, but . . . t h e i r basic therapeutic mechanism seems to be a reductive one; that i s , duce desirable  they pro-  effects only by reducing; the l e v e l of i n t e -  gration of the p a t i e n t , not by removing the cause or by o f f e r i n g something that the patient l a c k e d . . . . They reduce the psychic p o t e n t i a l i t i e s  of the patients  so that even  c e r t a i n psychopathological phenomena cannot be experienced." A r i e t i considers that p h y s i c a l treatment i s  useful  because psychotherapy i s available to only a small minority of p a t i e n t s ;  and because i t does not work i n every case even  i n the hands of the most experienced.  Also some cases with  concomitant p h y s i c a l i l l n e s s require r a p i d symptom r e d u c t i o n . In many cases symptomatic treatment impulses)  (or repression of i d  i s the best a v a i l a b l e f o r the p a t i e n t ,  and even  though not a cure, i t represses the a s o c i a l and a n t i s o c i a l symptoms.  F i n a l l y , p h y s i c a l therapy i s a very valuable  adjunct to psychotherapy since i t enables r a p i d improvement i n the patient so that he i s again able and motivated to r e l a t e to the t h e r a p i s t .  A r i e t i concludes with two warnings  against the use of p h y s i c a l treatment:  i t should not pro-  duce damage of serious proportions; nor should i t hinder or make impossible the ensuing or concomitant psychotherapy. 1 The s o c i a l worker should have some understanding  1 A r i e t i , oo. c i t . . pp. 482-483.  54  of the p h y s i c a l therapies,  since often he i s asked to  i n t e r p r e t t h e i r value or n e c e s s i t y , accept these forms of treatment.  and to help the patient  Most commonly used today  i n mental h o s p i t a l s are a s e r i e s of i n s u l i n or e l e c t r i c shock treatments,  and the use of a t a r a c t i c s or t r a n q u i l i z e r s  as medication over a period of time. Studies of the effects of p h y s i c a l therapy i n d i cate i n general that shock treatment ( i n s u l i n and e l e c t r o convulsive) may improve the prognosis i n those schizophrenic cases which already have a good outlook, hut are more successful  i n t r e a t i n g c e r t a i n depressions,  psychoses. 1  and manic-depressive  The use of shock treatments has diminished with  the increased use of t r a n q u i l i z e r s or a t a r a c t i c s , newest of the b i o l o g i c a l therapies and the most extensively used today. In general, the a t a r a c t i c s have a very d e f i n i t e therapeutic effect upon mental function and behavior. Violent, agitated,  anxious, a s s a u l t i v e ,  denudative  patients  on the whole show a decrease i n aggressive behavior, a lessened responsiveness  to d i s t u r b i n g h a l l u c i n a t i o n s and  delusions, and an increased degree of s o c i a l i z a t i o n with others.  This lessened emotional tension allows f o r more  contact with a l l t h e r a p i s t s .  The drugs diminish the  1 B r i t i s h Columbia P r o v i n c i a l Mental Health Services, P h y s i c i a n ' s Manual.  55 emotional expression of the abnormal thought content and afford a unique opportunity f o r intensive psychotherapy of patients i n whom such an approach was previously extremely difficult.1 The p h y s i c a l therapies used alone may favorably a l t e r symptoms and behavior, but the i n t e r n a l psychological processes of schizophrenia remain unchanged. mental h o s p i t a l s  Most p u b l i c  cannot offer i n d i v i d u a l psychotherapy, and  r e l y almost e n t i r e l y on p h y s i c a l therapies.  Drugs are not  used simply to eliminate management problems i n h o s p i t a l , however, since they do help the patient achieve a higher l e v e l of s o c i a l i n t e g r a t i o n and hence to p a r t i c i p a t e 2 f u l l y i n programs.  Ellsworth,  more  i n studying chronic schizo-  phrenic h o s p i t a l i z e d p a t i e n t s , concludes that the maximum effect from drugs can be reached only i n combination with a realistic,  aggressive, a c t i v i t y treatment program. With improved behavior following the use of  tranquilizers, from h o s p i t a l s .  today more schizophrenics are being discharged But since t h e i r i n t e r n a l emotional i l l n e s s e s  remain unchanged, the discharged patients require continued 1 B r i t i s h Columbia P r o v i n c i a l Mental Health Services, oo. c i t . 2 E l l s w o r t h , Robert B . , P h . d . , Beverley T. Mead, and William H. Clayton, M.S.W., "The R e h a b i l i t a t i o n and D i s p o s i t i o n of C h r o n i c a l l y H o s p i t a l i z e d Schizophrenic P a t i e n t s , " Mental Hygiene, v o l . 42, No. 3 (July 1958), p . 348.  56  i n d i v i d u a l i z e d out-patient care f o r vocational and s o c i a l rehabilitation.  This chore u s u a l l y f a l l s upon the s o c i a l  worker, although i f the patient i s s t i l l on medication, he w i l l require medical supervision as w e l l .  "Day" h o s p i t a l s ,  "half-way" and "family care" homes, as well as  out-patient  c l i n i c s can provide most of the advantages of h o s p i t a l care at a considerable lower cost to the p a t i e n t s or the community.  Such f a c i l i t i e s  are e s s e n t i a l adjuncts to modern,  r a p i d p h y s i c a l treatment i n mental h o s p i t a l s attacks of mental d i s o r d e r s .  of acute  The future trend i n treatment  of schizophrenia i s l i k e l y to be the extended use of such community, rather than h o s p i t a l , centres f o r prevention and a f t e r - c a r e , and the increasing use of s o c i a l workers to carry out these programs. Because i t i s believed that the r e l a t i o n s h i p with the f a m i l y , p a r t i c u l a r l y with the mother, i n the e a r l y years of l i f e plays a most important r o l e i n the development of schizophrenia, prevention centres l a r g e l y i n the p r o v i s i o n of s e c u r i t y f o r the c h i l d through warm, understanding relationships  i n the f a m i l y .  Since those who develop schizo-  phrenia seem to be drawn more often from among persons who i n childhood are withdrawn, shy and unsociable,  such  c h i l d r e n should be given e a r l y guidance d i r e c t e d toward the improvement of s o c i a l i z a t i o n .  S o c i a l workers can contribute  to the prevention of schizophrenia i n t h e i r work with  57 c h i l d r e n by spotting the e a r l y symptoms, obtaining p s y c h i a t r i c advice, and helping such c h i l d r e n toward a more secure home l i f e and better s o c i a l  adjustment.  CHAPTER III CASEWORK TREATMENT:  STUDY AND SOCIAL DIAGNOSIS  S o c i a l casework has been defined as "an art i n w h i c h knowledge of the science of human r e l a t i o n s and s k i l l i n r e l a t i o n s h i p s are used to mobilize c a p a c i t i e s  i n the  i n d i v i d u a l and resources i n the community appropriate  for  better adjustment between the c l i e n t and a l l or any part of h i s environment. 1 , 1 Casework i s a professional  service offered to  persons who cannot cope alone with c e r t a i n problems of d a i l y living.  It i s the process by which these problems are  r e l i e v e d or solved.  A good s o c i a l work approach perceives  the i n d i v i d u a l i n r e l a t i o n to h i s family and s o c i a l environment, not as an i s o l a t e d u n i t .  During the casework  process, the c l i e n t may be helped to cope more e f f e c t i v e l y with problems within himself, and at times h i s environment may he modified to r e l i e v e him of external pressures.  Both  approaches are therapeutic and may be used s i n g l y or simultaneously to mitigate i n t e r n a l c o n f l i c t s and external stress.  1 Bowers, 0. M. I . , "The Nature and D e f i n i t i o n of S o c i a l Casework," S o c i a l Casework, v o l . 30, No. 10 (December 1949)•  59 The m o b i l i z a t i o n of the c l i e n t ' s inner  capacities  and the use of environmental resources are accomplished through the r e l a t i o n s h i p between caseworker and c l i e n t . This r e l a t i o n s h i p i s b u i l t up over a period of time through the medium of the interview, or succession of i n t e r views.  The r e l a t i o n s h i p i s dynamic i n q u a l i t y and i s  established during the period of study and psychosocial assessment of the c l i e n t and h i s problem.  It  develops  throughout the treatment process, and i s therapeutic f o r the c l i e n t who i s an active p a r t i c i p a n t , enabling him to f i n d a more constructive s o l u t i o n to h i s problem.  In the r e l a t i o n -  s h i p , the s o c i a l worker exercises the "professional use of s e l f , " c o n t r o l l i n g and d i r e c t i n g the treatment process i n accordance with s o c i a l work p r i n c i p l e s and procedures, and adapting casework techniques to the c l i e n t ' s s p e c i f i c needs and problem. The basic concepts and p r i n c i p l e s of the casework method are applicable to any s e t t i n g i n which casework i s practiced.  Examples are respect f o r the i n d i v i d u a l ' s r i g h t  to self-determination, to f i n d h i s own s o l u t i o n to h i s problems; and acceptance of the c l i e n t as he i s , 1 without c r i t i c i s m or judgment.  Such concepts which are based on  common basic needs of people are adapted to the purpose and function of each s e t t i n g .  specific  The concern of t h i s  t h e s i s i s how casework i s adapted to meet the  special  60 problems and needs of the schizophrenic patient undergoing treatment i n a p s y c h i a t r i c c l i n i c or h o s p i t a l . Casework i n the P s y c h i a t r i c Setting Casework i n a c l i n i c a l s e t t i n g i s based on the concept of the patient as a member of the h o s p i t a l community, which has now replaced h i s normal family and s o c i a l environment, and to which he must l e a r n to adjust.  The p a t i e n t ' s  basic problem i s the malfunctioning due to h i s which has required h i s separation, from normal s o c i e t y .  illness  temporarily at l e a s t ,  In p s y c h i a t r i c casework, beginning  emphasis i s placed on the p a t i e n t ' s  feelings  about h o s p i t a l i -  z a t i o n and h i s new environment, and on h i s reactions to h i s i l l n e s s and to p s y c h i a t r i c treatment.  In a d d i t i o n , the  patient i s perceived i n r e l a t i o n to the l a r g e r community to which he s t i l l has t i e s and w i l l eventually r e t u r n , and emphasis i s placed also on h i s family r e l a t i o n s h i p s ,  his  employment and economic status, and the way he i s handling the d a i l y problems confronting him. The primary focus of casework i n a p s y c h i a t r i c s e t t i n g i s not the cure of the p a t i e n t ' s the a l l e v i a t i o n of h i s symptoms.  i l l n e s s , nor even  It i s to help the patient  cope more e f f e c t i v e l y with external r e a l i t y problems,  first  i n h o s p i t a l and l a t e r on i n the community, despite the handicaps imposed by the i l l n e s s .  P s y c h i a t r i c casework  has been defined as "the process of a s s i s t i n g an i n d i v i d u a l  61 i n the s o l u t i o n of problems a r i s i n g from a s i t u a t i o n external to himself.  Although the r e s o l u t i o n of i n t e r n a l  c o n f l i c t s i s not the primary focus of t h i s r e l a t i o n s h i p , the s o l u t i o n of the external problems i s achieved through the s k i l l f u l understanding on the worker's part of unconscious motivation and t h e i r manifestations  i n behavior.  The caseworker deals with those problems a r i s i n g i n inner c o n f l i c t , manifested i n some disturbance of p e r s o n a l i t y functioning. patient's  It may or may not include work with the  r e a l i t y s i t u a t i o n and environment." 1  Casework with the Schizophrenic Patient It i s impossible within the confines of t h i s t h e s i s to examine a l l aspects of casework p r a c t i c e with the schizophrenic p a t i e n t .  The aspect selected for discussion i s the  m o b i l i z a t i o n of the schizophrenic p a t i e n t ' s  inner  capacities  through d i r e c t casework r e l a t i o n s h i p therapy to enable him to more e f f e c t i v e l y cope with the problems of d a i l y l i v i n g . The schizophrenic person's main p e r s o n a l i t y problem i s perceived as the weakening or breakdown of h i s ego which r e s u l t s i n abnormal thought, perception and behavior due to a d i s s o c i a t i o n with r e a l i t y .  His second major problem i s a  lack of basic t r u s t i n people, stemming from e a r l y childhood,  1 Frechtman, Bernice W. and Committee, "Report of the Committee on the Role of the P s y c h i a t r i c S o c i a l Worker as Caseworker or T h e r a p i s t , " Journal of P s y c h i a t r i c S o c i a l Work, v o l . 20 (1950).  62 and  r e s u l t i n g i n an i n a b i l i t y t o form and m a i n t a i n  relationships.  The  schizophrenic's  weakened ego  object  causes  l o s s o f c o n t a c t w i t h r e a l i t y v a r y i n g from minimal t o h i s d i s t r u s t of p e o p l e i s m a n i f e s t e d i n poor s o c i a l s h i p s w i t h f a m i l y , f e l l o w employees, and  gross:, relation-  i n a l l social  situations. In t h i s Chapter, the method o f casework w i l l examined t o determine how the  schizophrenic  i t can be used t o h e l p  p a t i e n t ' s ego,  t a c t w i t h r e a l i t y , and  enable him  b r i n g him  strengthen  i n c l o s e r con-  t o form more i n t i m a t e  s a t i s f y i n g r e l a t i o n s h i p s by g a i n i n g some t r u s t i n the worker which u l t i m a t e l y i s t r a n s f e r r e d t o o t h e r s .  ego  the casework method may  team, the p a r t p l a y e d p a t i e n t s and  be n e c e s s a r y t o f i t the  schizophrenic  p s y c h i a t r i s t , nurse and  patient.  The  be  r o l e s p l a y e d by  the  fellow  the m o b i l i z a t i o n o f  o t h e r community r e s o u r c e s  aid i n h i s s o c i a l recovery,  w i l l not be d i s c u s s e d .  s o l e l y on t h a t p r o c e s s between caseworker the  of  o t h e r members o f the p s y c h i a t r i c  the h o s p i t a l m i l i e u , and  p a t i e n t which h e l p s  the  specific  i n the treatment p r o c e s s hy  the p a t i e n t ' s f a m i l y and  w i l l be  the  I t i s hoped t o determine what m o d i f i c a t i o n s  needs o f the  case-  f u n c t i o n i n g , r a t h e r than t o those o f  normal, n e u r o t i c o r s o c i o p a t h i c p e r s o n a l i t i e s , w i l l defined.  and  Those  s p e c i f i c casework t e c h n i q u e s which are a p p l i c a b l e t o schizophrenic's  be  l a t t e r to strengthen  ego  which Emphasis and  functioning  63 and improve s o c i a l relationships—although t h i s r e l a t i o n s h i p i s only one part of treatment and i n actual p r a c t i c e can never he i s o l a t e d from the use of the team, h o s p i t a l , family and community resources. Selected to describe t h i s one aspect of casework i s the statement by Jules Coleman that " . . . casework i s the method of psychological treatment concerned with the r e a l i t y aspects of ego f u n c t i o n i n g .  Its purpose i s to stimulate  the  automatic organizational and i n t e g r a t i o n a l impulses of the ego i n dealing with r e a l i t y problems. attitude ation r e :  In i t s  therapeutic  i t attempts to create an optimal transference  situ-  a p o s i t i v e r e l a t i o n s h i p and to maintain i t  through focus on current material and r e a l i t y - o r i e n t e d i n t e r p r e t a t i o n and by avoiding dependency s t i m u l a t i o n .  It  i n t e r p r e t s pre-conscious material . . . to allow the c l i e n t to dispense with the presenting screen of d i s t o r t i o n and misconception.1,1 Each part of the casework process, the study and exploration p e r i o d , the s o c i a l diagnostic phase, the planning and treatment process, and the termination of the treatment r e l a t i o n s h i p , w i l l he examined and applied to treatment of the schizophrenic's c e n t r a l problems.  In  1 Coleman, J u l e s , "Psychotherapeutic P r i n c i p l e s i n Casework Interviewing," American Journal of P s y c h i a t r y , v o l . 108, No. 4 (October 1951), p . 298. ,  64 a d d i t i o n , the r e l a t i o n s h i p between the caseworker and the schizophrenic patient w i l l he discussed,  as well as the  requirements of the caseworker to act as  therapist.  F i n a l l y , a comparison between casework and psychotherapy w i l l he made, and an attempt to describe why and how the casework method i s appropriate f o r t r e a t i n g schizophrenia. The Casework Treatment Process The problem-solving process of s o c i a l i s comprised of four important s t e p s : 1 diagnosis,  study,  casework social  treatment planning, treatment and i t s  evaluation.  The c l i e n t comes to the caseworker f o r help with h i s problem. In order to understand the c l i e n t , h i s problem, h i s "worka b i l i t y " or "the combined motivation and capacity to deal 2 with h i s problem" effectively,  and how to help the c l i e n t most  the caseworker must f i r s t  study the " c l i e n t i n  h i s t o t a l s i t u a t i o n , " using various frames of reference. Because behavior i s the expression of the c l i e n t ' s pers o n a l i t y as he reacts to h i s environment, a l l the modes of behavior u t i l i z e s hy the c l i e n t w i l l be observed.  The  f u l l e r the study, the nearer i s the caseworker to seeing the 1 A more popular d e s c r i p t i o n , i n current use, of these four phases i s : assessment, planning of s e r v i c e , implementation of p l a n , and evaluation of service given. 2 Perlman, Helen H a r r i s , S o c i a l Casework. The U n i v e r s i t y of Chicago Press, 1957, p . 183.  65  " t o t a l person" and the more exact the diagnosis,  planning  and treatment* The Study Phase "The  study phase i s the i n i t i a l period i n the  casework process i n which pertinent s o c i a l , somatic and psychological f a c t s about the c l i e n t and h i s family are obtained by the caseworker i n a systematic  way."  1  I t con-  tinues u n t i l s u f f i c i e n t knowledge i s gained about the his  client,  family group, and h i s l i f e s i t u a t i o n , to plan an appro-  p r i a t e kind of help f o r the c l i e n t , and u n t i l the c l i e n t understands and can accept the treatment p l a n .  During t h i s  period, the i n i t i a l r e l a t i o n s h i p between caseworker and c l i e n t i s formed.  I t i s e s s e n t i a l that the c l i e n t con-  s c i o u s l y understands and a c t i v e l y p a r t i c i p a t e s i n the study of h i s s i t u a t i o n .  During t h i s period of observation,  the  caseworker w i l l e l i c i t both subjective and objective f a c t s about the c l i e n t and h i s s i t u a t i o n . He w i l l obtain data concerning  the c l i e n t ' s p h y s i c a l and mental state; h i s  i n t e r a c t i o n with f a m i l y and others i n the community; h i s h i s t o r y of psychosocial development; and h i s present  level  of s o c i a l functioning* I n i t i a l contact with the schizophrenic  patient  1 Family Service A s s o c i a t i o n of America, Method and Process i n S o c i a l Casework. New York, 1 9 5 8 * P» 9 »  66 d u r i n g the s t u d y p e r i o d p r e s e n t s s p e c i a l problems.  The  caseworker's a t t i t u d e and approach w i l l be d i s c u s s e d more f u l l y under the l a t e r s e c t i o n s on t r e a t m e n t method and the p r o f e s s i o n a l r e l a t i o n s h i p between caseworker and p a t i e n t . I t s h o u l d be mentioned, however, t h a t the caseworker must p r o c e e d s l o w l y t o overcome the s c h i z o p h r e n i c ' s b a s i c mist r u s t and t o a l l o w f o r h i s p s y c h i c f r a g i l i t y .  The  schizo-  p h r e n i c p e r s o n s h o u l d n e v e r be t r e a t e d as though he has a n o r m a l l y f u n c t i o n i n g ego.  U n l i k e the s o c i o p a t h and n e u r o t i c ,  he u s u a l l y cannot d e f i n e h i s problem, does n o t seek h e l p but i s d i r e c t e d t o the caseworker f o r s e r v i c e , and cannot verbalize his d i f f i c u l t i e s  except i n the vaguest terms.  The caseworker must be v e r y a c t i v e i n e l i c i t i n g  information  f r o m the s c h i z o p h r e n i c p a t i e n t s i n c e i n i t i a l l y he w i l l unable t o u n d e r s t a n d h i s problem, n o r how by the caseworker t o cope w i t h i t . no comprehension  be  he can be h e l p e d  He w i l l have l i t t l e  or  o f the treatment p r o c e s s and much c l a r i -  f i c a t i o n , u s u a l l y i n terms o f what c o n c r e t e s e r v i c e the caseworker can immediately o f f e r , w i l l be n e c e s s a r y .  The  caseworker s h o u l d be c a r e f u l t o c o v e r a l l a s p e c t s o f the p a t i e n t ' s c u r r e n t s i t u a t i o n b o t h a t home and a t h o s p i t a l , i n o r d e r n o t t o miss a problem the p a t i e n t cannot v e r b a l i z e . For  example, a p a t i e n t may  have a c h i l d i n need o f  immediate  c a r e , but w i l l make no mention o f h i s f a m i l y f o r s e v e r a l days o r even weeks.  Gaps i n the p a t i e n t ' s account o f h i s  s i t u a t i o n must be f i l l e d as q u i c k l y as p o s s i b l e from f a m i l y  67  and other sources.  Nursing s t a f f are invaluable i n p i c k i n g  up clues to the p a t i e n t ' s  problems, since the nurse has the  longest period of observation, gains the quickest r e l a t i o n ship with the p a t i e n t ,  and u s u a l l y hears the f i r s t  complaints.  The problem i n i t i a l l y presented by the schizophrenic patient i s customarily an environmental, rather than a personal, one, concerning c h i l d r e n , c l o t h i n g , v i s i t s ,  etc.  The caseworker should he very active i n d e f i n i n g and c l a r i fying the p a t i e n t ' s as possible  problems, and g i v i n g as r a p i d service  to h i s needs.  A d e f i n i t e focus and goal needs  to he set i n the beginning with the schizophrenic patient and adhered to since he gains reassurance from t h i s r e a l i t y approach.  The caseworker should avoid discussing areas which  the patient finds d i s t u r b i n g , and obtain data about these from another source.  In the study phase, d i r e c t  questions  which f r i g h t e n the patient or anger him should be avoided, as well as topics arousing adverse  feelings.  During the study p e r i o d , the caseworker w i l l attempt to gain information from the p a t i e n t , h i s  relatives  or others, to determine the p a t i e n t ' s  structure,  personality  the extent of h i s pathology, the immediate problem and whether i t can be a l l e v i a t e d by casework s e r v i c e , patient's  the  motivation and capacity for h e l p , and an appraisal  of the family s i t u a t i o n i n r e l a t i o n to the patient and h i s problem.  Data on the p a t i e n t ' s  developmental, educational  68 and employment background should be c o l l e c t e d , and on h i s financial  situation. Of c r i t i c a l importance i n making the s o c i a l diag-  nosis and treatment plan i s an appraisal of the  patient's  optimal l e v e l of s o c i a l functioning, and what external s t r e s s e s , i f any, p r e c i p i t a t e d h i s present attack. caseworker should determine at what periods,  The  and f o r how  long, the patient functioned most normally, since the purpose of the h o s p i t a l i z a t i o n i s to r e t u r n him to t h i s l e v e l . The attack n e c e s s i t a t i n g h o s p i t a l i z a t i o n i s viewed as a regression from t h i s optimal l e v e l and i f p o s s i b l e , i n the p a t i e n t ' s  environment which contributed to t h i s  regression should be determined. apparent,  the p a t i e n t ' s efforts  No external stress may be  i n which case i n t e r n a l c o n f l i c t s — t h e  itself—caused  stresses  the attack.  illness  Often, however, some change i n  external s i t u a t i o n proved i n t o l e r a b l e and  to remove t h i s stress i n future are e s s e n t i a l .  The  number, type and duration of previous attacks and h o s p i t a l i zations should be examined to determine what external stresses have proven i n t o l e r a b l e , and what measures have been successful  i n maintaining the p a t i e n t ' s  best l e v e l of  social functioning. A l o n g i t u d i n a l or h i s t o r i c a l view i s necessary to assess the p a t i e n t ' s  premorbid p e r s o n a l i t y i n terms of how  he functioned before the onset of the i l l n e s s .  What were  69 h i s outstanding p e r s o n a l i t y t r a i t s or weaknesses which have r e s u l t e d from inheritance and development?  What was h i s  p e r s o n a l i t y structure before h i s i l l n e s s and to what degree has the schizophrenic process impaired t h i s The caseworker must d i f f e r e n t i a t e  structure?  between general  ineffec-  tiveness due to low i n t e l l e c t , poor p h y s i c a l c o n d i t i o n , lack of t r a i n i n g , e t c . and the impairment i n the  patient's  t o t a l f u n c t i o n a l capacity d i r e c t l y due to the schizophrenic disorder. patient's  Often the caseworker neglects to assess the underlying p e r s o n a l i t y weaknesses and sets  u n r e a l i s t i c treatment goals, expecting that improvement i n the p a t i e n t ' s  schizophrenic c o n d i t i o n w i l l a l t e r h i s basic  personality. The S o c i a l Diagnostic Phase The next step i n the casework process i s the s e l e c t i o n of pertinent f a c t s from the data obtained i n the study phase f o r the purpose of making a s o c i a l  diagnosis.  This i s the key to the whole treatment process, since upon the caseworker's  s k i l l i n diagnosis r e s t s the treatment  p l a n , and the implementation of t h i s p l a n .  The worker must  evaluate the s i g n i f i c a n t factors causing or c o n t r i b u t i n g to the c l i e n t ' s malfunctioning, i n order that he may a r r i v e at a treatment plan which w i l l resolve or a l l e v i a t e the problems.  client's  The c l i e n t ' s c e n t r a l problems must be i d e n t i f i e d  as well as those underlying h i s d i f f i c u l t i e s s a t i s f a c t o r y s o c i a l adjustment.  i n making a  His willingness to accept  70 treatment and motivation to change must be assessed, as well as h i s desire to p a r t i c i p a t e  i n actual treatment.  The case-  worker w i l l also evaluate the c l i e n t ' s a b i l i t y to help hims e l f i n coping with h i s problems, h i s capacity f o r his situation r e a l i s t i c a l l y ,  seeing  and the adequacy of the  resources he can e n l i s t to help him resolve h i s  difficulties.  Various approaches are used i n making the s o c i a l diagnosis.  Through an analysis  of the c l i e n t ' s r o l e s ,  l e v e l of s o c i a l functioning i s ascertained,  the  and the areas  of c o n f l i c t and confusion i n performing the duties required of these r o l e s are i d e n t i f i e d .  The a p p l i c a t i o n of  "ego  psychology" to casework p r a c t i c e i s an example of one of the most popular current casework trends.  In t h i s approach,  treatment i s designed to strengthen the c l i e n t ' s ego thus permitting him to make a h e a l t h i e r and more adequate s o c i a l adjustment.  The ego has been defined as "the sum t o t a l of  the i n t e g r a t i n g e f f o r t s  of the p e r s o n a l i t y .  The ego  receives s t i m u l i from the i d , from external r e a l i t y , and from the s u p e r e g o . . . .  Thus from b i r t h onwards, the ego  develops methods of dealing with chaotic d r i v e s ,  external  danger, and superego p r o h i b i t i o n s . 1 , 1 In casework treatment,  given the c l i e n t ' s  desire  1 Parad, Howard J . , e d . , Ego Psychology and Dynamic Casework. Family Service A s s o c i a t i o n of America, New York, 1958, p . 43.  71 to change h i s adjustment to an external s i t u a t i o n , degree to which he i s successful  the  i n accomplishing t h i s  is  l a r g e l y dependent upon the strength of those portions of the p e r s o n a l i t y which are summed up as the ego.  The ego's  function i s to carry out co-ordinated r a t i o n a l behavior, designed to maintain the i n d i v i d u a l i n a state of e q u i l i brium with h i s environment.  In b r i e f the tasks of the ego  are to perceive i n s t i n c t u a l needs and external r e a l i t y upon which s a t i s f a c t i o n  of these needs depend; and to  co-ordinate and integrate  Id impulses with one another and  with the requirements of the superego and adapt them to environmental c o n d i t i o n s • 1 The e f f i c a c y with which the ego discharges these v a r i e d duties fluctuates  i n proportion to both i n t e r n a l and  external stresses that the i n d i v i d u a l i s experiencing at any given time.  This concept of stress i s  important consideration i n diagnosis.  another  When a person comes  seeking help with a problem, h i s apparent ego strength may be diminished because of the s t r e s s - s i t u a t i o n i n which he finds himself.  Thus ego strength must be measured i n  accordance with the c l i e n t ' s age,  stage i n psychosocial  development, p h y s i c a l and mental endowment, together with the r e a l i s t i c  stresses under which he i s t r y i n g to f u n c t i o n .  1 Parad, on. c i t . . p . 4-3.  72 Because of t h i s , the caseworker can only accurately assess the c l i e n t ' s ego strength hy taking i n t o consideration a h i s t o r i c a l view:  how he performed i n the past and solved  problems i n h i s l i f e s i t u a t i o n . When the e q u i l i b r i u m between the i n d i v i d u a l and h i s environment i s disturbed, the ego seeks to restore the balance by the use of mechanisms of defense.  These are  systematized, standardized reactions of the p e r s o n a l i t y designed to a l l a y anxiety and secure substitute factions.  satis-  Defense mechanisms are " . . . the various  adjustive  techniques hy which i n d i v i d u a l s s t r i v e to protect the pers o n a l i t y , to s a t i s f y i t s emotional needs, to e s t a b l i s h and maintain harmony among i t s c o n f l i c t i n g tendencies, to reduce tension and anxiety a r i s i n g from unacceptable impulses that must be counteracted or r e s t r a i n e d , or to modify r e a l i t y i n order to make i t more t o l e r a b l e and acceptable."1  To cope adequately, the ego must be able to  employ many types of defenses and to use them appropriately. To assess ego strength, the caseworker must he aware of the kinds of defenses used by the c l i e n t , t h e i r  effectiveness  and r i g i d i t y . To summarize, the caseworker's s o c i a l  diagnosis  must i n c l u d e :  1 Noyes and Kolb, Modern C l i n i c a l P s y c h i a t r y , p . 43.  73 1.  I d e n t i f i c a t i o n of c e n t r a l problems;  2.  assessment of ego functioning and defense mechanisms;  3.  evaluation of external s t r e s s e s , past and current l e v e l of s o c i a l functioning; and  4.  determination of motivation and capacity to change, and to accept and use help i n s o l v i n g problems. In the c l i n i c a l s e t t i n g ,  the p s y c h i a t r i c  diagnosis  i s made by the p s y c h i a t r i s t using the combined findings of the various team members.  The caseworker i s  frequently  asked to c o l l e c t the s o c i a l h i s t o r y , and assess the  patient's  s o c i a l s i t u a t i o n , as h i s c o n t r i b u t i o n to the p s y c h i a t r i c diagnosis.  Once the disorder has been c l a s s i f i e d  schizophrenia, the caseworker knows that the  as  patient's  main problem i s a breakdown i n ego f u n c t i o n i n g . "Ego Breakdown" i n Schizophrenia The main function of the ego i s to mediate between i n s t i n c t u a l drives (the Id) and external r e a l i t y . The ego "boundary" acts as a sensory organ which separates the i n d i v i d u a l from the outside world. can d i f f e r e n t i a t e  The healthy ego  c l e a r l y between what i s inside ( i . e .  thoughts, f a n t a s i e s , emotions, memories) and what i s side ( i . e .  his  out-  a r e a l object or event i n the external world).  In schizophrenia, the ego boundary breaks down so that the patient can no longer d i s t i n g u i s h between what i s happening within himself and i n the outside world.  He becomes  74 uncertain and confused as to h i s own i d e n t i t y , as separate from the world around him.  He can confuse himself, and  parts of h i s body, with others and with objects i n h i s immediate environment, or h i s "body image" becomes d i s torted.  This d i s s o l u t i o n of the ego boundary, t h i s  dis-  t o r t i o n of perception between inner and outer world, and the accompanying l o s s of a sense of personal i d e n t i t y ,  is  the c e n t r a l feature of the schizophrenic p r o c e s s . 1 The breakdown of ego boundaries i n schizophrenia r e s u l t s i n a break with r e a l i t y , and a l l functions of the ego become impaired.  Such secondary ego functions  as  perception, memory, and a b i l i t y to symthesize,  to i n t e -  grate, to comprehend, to organize are affected  to varying  degrees.  The patient not only misinterprets  stimuli i n his  present outer world but confuses these with past memories. Time becomes d i s t o r t e d ,  and past and present intermingle.  For example, events i n the p a t i e n t ' s distant past may be felt  as though they had just occurred.  Orderly, r a t i o n a l  thought i s l o s t , and primary process t h i n k i n g emerges. Rules of l o g i c , of time and space, of cause and effect cease to e x i s t .  The world i s perceived i n terms of magic  and wish f u l f i l l m e n t .  Instead of o r d e r l y , r e a l i t y - o r i e n t e d  thought processes, there i s the use of primary process  1 Federn, P a u l , Ego Psychology and the Basic Books, New York, 1952.  Psychoses.  75 mechanisms of displacement, and concrete t h i n k i n g .  condemnation, symbolic thought  The p a t i e n t ' s  speech becomes  b i z a r r e and seemingly purposeless, since he combines and responds to past memories, present thoughts, and random s t i m u l i i n h i s environment, each as they occur.  Auditory  and v i s u a l h a l l u c i n a t i o n s occur when the patient  perceives  h i s own thoughts and f e e l i n g s self.  as coming from outside him-  Thus he claims to see and hear what does not e x i s t  i n external r e a l i t y , but i s a part of h i s own mental and body processes.  Delusions are simply an attempt to explain  the confusion caused by the perceptual disturbances make some order out of chaos.  and to  The patient t r i e s to explain  or r a t i o n a l i z e what he perceives inside himself i n terms of external  reality.1  Thus d e l u s i o n a l formation i s a constructive, not destructive,  effort  on the ego's part to create orderly  thought, to synthesize perceptual experiences, explanations f o r the p a t i e n t ' s  by f i n d i n g  various symptoms.  example of t h i s tendency towards health i s the  An  paranoid's  t i g h t l y - k n i t system of delusions which leaves large areas of the psyche free to function normally.  Without delusions,  the world of the schizophrenic would be c h a o t i c , strange, fragmented and incomprehensible.  1 Freeman, Thomas, Cameron, John L . and Andrew McGhie, Chronic Schizophrenia. Tavistock P u b l i c a t i o n s , London, 1958, pp. 62-65.  76  Ego Functioning of the Schizophrenic The ego of the schizophrenic w i l l never function normally.  Its  strengths and weaknesses should he  evaluated  i n r e l a t i o n to a hypothetical concept of optimal ego functioning f o r the schizophrenic person, not i n r e l a t i o n to what the average normal ego can achieve.  Schizophrenia  i s a process which the i n d i v i d u a l can never change once i t is started.  It i s a permanent character  structure.  "Once schizophrenic, always s c h i z o p h r e n i c . r t l  The schizo-  phrenic process may, however, take i t s f u l l course to gross d e t e r i o r a t i o n i n ego functioning, or may come to a stands t i l l at any point i n i t s development.  The caseworker  should he f a m i l i a r with the course of the schizophrenic breakdown, and be able to i d e n t i f y which phase the i s i n when referred f o r casework s e r v i c e . the p e r s o n a l i t y d i s i n t e g r a t e s slowly.  patient  In schizophrenia,  The patient may  make a rather good adjustment f o r many years with a very slow change to the better or worse.  However, preceding  the acute outbreak of the i l l n e s s which necessitated hospitalization,  there i s frequently a period of withdrawal.  It seems as i f the ego has fought a long time to keep up i t s i n t e r e s t i n the world, then a sudden collapse sets i n . . . • More often the period of withdrawal i s c l i n i c a l l y mute, long l a s t i n g and not noticed hy the p a t i e n t ' s  1 Beck, S . J . , "The Six Schizophrenias," American Orthopsvchiatric A s s o c i a t i o n : Research Monograph V I . p . 143.  77 environment, often not even by the patient himself. In the second phase, that of c o l l a p s e , the patient f e e l s dreamlike, d i s organized, unable to comprehend what i s going on around him; the ego i s fragmented:, everything i s unreal and c h a o t i c . In the state of r e s t i t u t i o n , when the ego again pushes towards r e a l i t y , one finds the delusional system s e t t i n g in—the attempt to explain the psychotic perception of the world.I The caseworker therefore must gain two pictures of the p a t i e n t ' s ego functioning:  what are the present  ego strengths and weaknesses as casework begins;  and how  well d i d the ego function during periods i n the past when the patient showed the best s o c i a l adjustment.  The case-  worker must assess the present impairment i n ego functioning and contrast  i t with the higher l e v e l achieved somewhere i n  the p a t i e n t ' s p a s t .  The goal of casework treatment w i l l be  to help strengthen the p a t i e n t ' s ego so that i t can function as w e l l as, or better than, the optimal l e v e l achieved i n the p a s t . To evaluate present impairment due to the breakdown, the caseworker w i l l assess whether the higher ego functions have been preserved during the attack, only temporarily impaired, or whether permanently damaged.  To  what extent were these higher functions developed before  1 E i s s l e r , K. R . , "Remarks on the Psychoanalysis of Schizophrenia," Psychotherapy with Schizophrenia: a Symposium, International U n i v e r s i t y Press, New York, 1952, p . 160.  78 the breakdown?  Has the present impairment continued over  a long period of time so that i t appears permanent, or d i d ego functioning seem to deteriorate r a p i d l y ?  The case-  worker w i l l use evaluations of a l l team members to determine the degree, nature and permanency of the ego breakdown, i n order not to agree with the patient on u n r e a l i s t i c plans f o r h i s future.  The caseworker w i l l look c a r e f u l l y at the  s e v e r i t y , form, and the trend of ego d i s o r g a n i z a t i o n , Is i t m i l d , severe? employed? long?  How long have these symptoms been  How many periods of maladjustment and f o r how  How well d i d the patient recover?  siderations the treatment prognosis In examining the p a t i e n t ' s  Upon these con-  depends. ego functions, many  questions w i l l be considered to determine what factors  are  working towards the p a t i e n t ' s recovery, and which seem to impede i t .  To what degree i s the patient r e a l i t y oriented?  Does he know where he i s and why he was brought to hospital? Can he give a f a i r l y r a t i o n a l account of h i s background and s i t u a t i o n , or i s he confused as to time and the sequence of events?  Does he show any awareness that he i s disturbed,  or does he blame others f o r h i s h o s p i t a l i z a t i o n and deny any problems?  Does he r e a l i z e the l i m i t s imposed by h i s  i l l n e s s or give grandiose accounts of past achievements and present u n r e a l i s t i c plans f o r h i s future?.  How f u l l  a  l i f e i s he able to l i v e despite h i s symptoms?  Does he t a l k  79  to nurses and other patients  or become agitated or withdrawn  at the threat of s o c i a l contacts?  Is he able to care f o r  himself personally or does he need much supervision hy nursing s t a f f ?  Does he show i n t e r e s t i n the ward program,  i n r e c r e a t i o n a l and occupational outlets?  Such questions  as these w i l l determine to what degree the patient  has  adjusted t o , and i s i n contact with, h i s new environment. The caseworker w i l l he able to determine the degree of impairment i n the p a t i e n t ' s  higher ego functions  hy questioning and l i s t e n i n g to the patient during the assessment interviews.  Is the p a t i e n t ' s  disorganized and seemingly i r r a t i o n a l ?  thinking confused, Can he answer  d i r e c t questions or concentrate and focus h i s thoughts, are h i s answers rambling and i r r e l e v a n t ?  To what degree  can the patient perceive cause and effect  both i n h i s  present and past situation? adaptation?  or  What i s h i s capacity for  Does he see only one s o l u t i o n to h i s problem,  such as leaving h o s p i t a l immediately, or can he verbalize any problem? stration?  How able i s he to tolerate  stress and f r u -  To what measure i s he w i l l i n g to wait for  r e s u l t s and not want immediate g r a t i f i c a t i o n ? to c o n t r o l h i s impulses?  Is he able  Does he suffer from delusions  and h a l l u c i n a t i o n s and i f so, how preoccupied i s he with these?  Such questions w i l l afford the caseworker with a  more s p e c i f i c than general approximation of ego strengths  80 and weaknesses and represents an operational of ego  examination  functions. These same questions should be applied i n assessing  the p a t i e n t ' s past l e v e l of s o c i a l f u n c t i o n i n g .  Knowledge  of the educational achievements i s valuable to assess the degree of i n t e l l i g e n c e as well as the p a t i e n t ' s a b i l i t y to organize t h i n k i n g , concentrate, past.  set goals, e t c . i n the  What are the p a t i e n t ' s r e l a t i o n s h i p s with h i s family  and was he able to maintain any close or intimate f r i e n d ships?  Prom study of the p a t i e n t ' s employment record,  examination of h i s material assets and finances,  and  assessment of h i s home s i t u a t i o n , the degree of maturity i n carrying out adult r o l e s can be determined. Defense Mechanisms of the Schizophrenic Patient In assessing the defenses employed by the schizophrenic p a t i e n t ,  some comparison with normal, neurotic and  sociopathic defenses i s h e l p f u l . as the ego develops, at d i f f e r e n t  In each s p e c i f i c phase  i t uses d i f f e r e n t defenses and a r r i v e s  solutions,  as i t copes with c o n f l i c t s  to r e a l i t y and the i n s t i n c t u a l d r i v e s .  related  The mature normal  ego uses a large v a r i e t y of defenses and i s f l e x i b l e adapting them to d i f f e r e n t  stresses.  in  Such defenses are  used c o n s t r u c t i v e l y to preserve ego functioning and at minimal cost of psychic energy.  In p a r t i c u l a r the mature  ego uses repression to i n h i b i t i n s t i n c t u a l drives and  81 protect i t from unconscious c o n f l i c t s , thus permitting the more s a t i s f a c t o r y expression of other ego functions. The defenses available to the immature ego are more p r i m i t i v e and l e s s stable than those developed l a t e r on.  " I n the schizophrenic p e r s o n a l i t y , p r i m i t i v e defenses  such as d e n i a l , p r o j e c t i o n , turning against the s e l f , r e v e r s a l into the opposite,  and detachment of l i b i d o —  are the most c h a r a c t e r i s t i c . " 1  Due to the extreme  anxiety  and tendency to c o n f l i c t i n schizophrenia, such defenses are used constantly, even when not appropriate, prevent successful  and thus  maintenance of ego functions.  The  schizophrenic person cannot use repression and i s  therefore  much more influenced by the unconscious. " I t has been said that neurosis i s to be a defense,  considered  a mask of an underlying psychosis,  and  that once the neurotic defenses break down, the psychosis appears.  C o n v e r s e l y , . . . recovery of the schizophrenic  patient can occur only through the reestablishment  of the  p  neurotic defenses."  Unlike the schizophrenic person, the  neurotic d i r e c t l y f e e l s and expresses h i s anxiety, or attempts to c o n t r o l i t by such defenses as  depression,  1 Beres, David, M . D . , "Ego Deviation and the Concept of Schizophrenia," Psychoanalytic Study of the C h i l d , v o l . 11 (1956), p . 211. 2 I b i d . . p.  212.  82 conversions, d i s s o c i a t i o n , displacement, phobia formation, or r e p e t i t i v e thoughts and a c t s * 1  The neurotic person's  defenses do protect him, though, at considerable c o s t , from much unconscious c o n f l i c t so that h i s ego can maintain contact with r e a l i t y and a sense of personal i d e n t i t y . S i m i l a r l y the sociopathic p e r s o n a l i t y r e t a i n s a f a i r l y normal perception of r e a l i t y and h i s own i d e n t i t y , and can repress unconscious d r i v e s .  The sociopathic p e r s o n a l i t y i n  fact suffers minimal subjective anxiety, since  expression  of h i s Id impulses go seemingly unpunished by a weakened conscious  Superego. Knowledge of the difference i n the defensive  pattern of the schizophrenic from that of other p e r s o n a l i t y types i s e s s e n t i a l to the caseworker i n s e l e c t i n g appropriate treatment techniques, which w i l l be discussed i n the next Chapter. Stresses and Resources i n the Schizophrenic P a t i e n t ' s Environment The assessment of external stresses which c o n t r i buted to the schizophrenic p a t i e n t ' s breakdown, and evalua t i o n of resources i n the family and community which may help i n h i s recovery, need only b r i e f mention.  These steps  1 B r i t i s h Columbia P r o v i n c i a l Mental Health Services, P h y s i c i a n ' s Manual.  83 i n the caseworker's s o c i a l diagnosis are the same i n assessing the schizophrenic patient as f o r any c l i e n t seeking casework service i n other s e t t i n g s .  Environmental  m o d i f i c a t i o n , while not the d i r e c t focus of t h i s i s e s s e n t i a l i n t r e a t i n g the schizophrenic.  thesis,  Since r e a l i t y  became so p a i n f u l he was forced to r e t r e a t from i t , imperative that the schizophrenic p a t i e n t ' s  it  is  external  environment be made more t o l e r a b l e to encourage h i s r e t u r n . The caseworker w i l l assess which i n t e r e s t s , hobbies, and employment opportunities can best be used to help the patient resume touch with the r e a l world.  In a d d i t i o n ,  those i n d i v i d u a l s i n the family and community who are interested i n helping the p a t i e n t ,  and i n whom the patient  has some measure of t r u s t , w i l l be used i n the  treatment  process to bridge the gap from the psychotic inner world of the schizophrenic patient to r e a l i t y . setting,  In any c l i n i c a l  much of the caseworker's time w i l l he devoted to  a l t e r i n g the p a t i e n t ' s environment to meet the l i m i t s imposed by h i s i l l n e s s ,  and working with r e l a t i v e s ,  friends  and employers i n i n t e r p r e t i n g the schizophrenic p a t i e n t ' s needs. The Schizophrenic P a t i e n t ' s Use of Casework Treatment More pertinent to the focus of t h i s t h e s i s i s the assessment of the schizophrenic p a t i e n t ' s motivation and capacity to change, and to accept and use help by the casework process.  As has been previously s t a t e d , the  84 schizophrenic patient i s not motivated to seek treatment, nor i n t e r e s t e d i n gaining i n s i g h t i n t o h i s p e r s o n a l i t y disturbance. grated:  His ego i s weak, unorganized and d i s i n t e -  he may not be i n s u f f i c i e n t contact with the r e a l  world to take an active part i n h i s own therapy.  His  capacity to change i s l i m i t e d to the degree of permanent impairment of ego functioning.  The schizophrenic u s u a l l y  denies any problems which arouse c o n f l i c t and t r i e s r e t r e a t from, rather than attempt to s o l v e , h i s  to  difficulties.  He i s hampered i n forming a r e l a t i o n s h i p with the caseworker due to h i s basic mistrust of people g e n e r a l l y .  He i s  able  to r e l a t e but a f r a i d t o , and h i s withdrawal i s a defense due to  despair. Despite these negatives,  the schizophrenic patient  can accept and use casework treatment: can be fostered and the p a t i e n t ' s be increased.  motivation f o r help  capacity f o r change can  The casework approach to achieve these ends,  however, i s d i f f e r e n t from that used with p e r s o n a l i t i e s having stronger egos which are i n contact with r e a l i t y . How the schizophrenic patient i s reached by the caseworker and helped to use the casework process,  w i l l be further  elaborated i n the discussion of the next phases of pi arming and implementing treatment.  CHAPTER IV CASEWORK TREATMENT:  PLANNING AND IMPLEMENTATION  Once the caseworker has concluded h i s diagnostic summary of the c l i e n t , he i s ready to formulate a treatment plan.  "It has been s a i d that the greatest mistake of  s o c i a l workers i n the past has been t h e i r attempt to take over the function of the c l i e n t ' s ego instead of t r y i n g to strengthen i t . " 1  The purpose of the casework plan i s to  give d i r e c t i o n to the caseworker i n h i s e f f o r t s the c l i e n t solve h i s problems.  to help  The p l a n should be based  on the kind of help the c l i e n t needs and that he i s ready and w i l l i n g to accept.  No treatment can occur unless the  c l i e n t i s an active p a r t i c i p a n t i n the treatment  process.  He cannot be given help unless he can accept and use i t to help h i m s e l f .  The treatment goal i s set during t h i s phase  of the casework process,  which may be one of complete  r e s o l u t i o n of the c l i e n t ' s problems, or a much more l i m i t e d objective.  A treatment method i s then chosen which i s  appropriate f o r the p a r t i c u l a r c l i e n t , h i s problems and needs.  1 Davidson, Evelyn H . , "Therapy i n Casework," S o c i a l Work, v o l . 12, No. 3 (July 1955), p . 81.  86 Casework treatment has been separated i n t o two d i s t i n c t methods:  the supportive treatment method and the  modifying treatment method. 1  Each uses a p a r t i c u l a r  c o n s t e l l a t i o n of techniques.  The supportive method i s used  when there i s no intent to modify the c l i e n t ' s ego mechanisms of defense.  This method receives the most use  i n casework p r a c t i c e , and almost always precedes use of the modifying method hy which the intent of treatment i s to help the c l i e n t a l t e r h i s defense mechanisms. methods can he combined, used a l t e r n a t e l y or As the caseworker reevaluates  These two separately.  the c l i e n t and h i s s i t u a t i o n  during progression of treatment, other techniques may be selected and the treatment goal a l t e r e d .  Some of the  techniques used i n the supportive method are:  reassurance,  g i v i n g information, l o g i c a l d i s c u s s i o n , demonstrating behavior, advice and guidance, s e t t i n g r e a l i s t i c l i m i t s , v e n t i l a t i o n , d i r e c t i n t e r v e n t i o n , u t i l i z a t i o n of h a b i t u a l patterns of behavior, and confrontation.  p  The modifying method i s predominantly the use of the technique of c l a r i f i c a t i o n and i s always accompanied hy supportive measures as the c l i e n t struggles to modify  1 Family Service A s s o c i a t i o n of America, Method and Process i n S o c i a l Casework, p . 15. For the purpose of t h i s t h e s i s , t h i s d i v i s i o n of casework i n t o the supportive and modifying treatment methods, has been found the most useful of those c u r r e n t l y i n use f o r analysis of casework treatment with the schizophrenic p a t i e n t . 2 I b i d . . pp. 17-18.  87 the stereotyped behavioral patterns that impair h i s s o c i a l functioning.  Choice of method and techniques i n treatment  depends on the assessment of the c l i e n t ' s ego  strengths;  h i s tolerance to f r u s t r a t i o n and capacity to withstand the anxiety connected with modifying h i s h a b i t u a l responses; h i s needs; and h i s motivation to change.  Generally speaking,  c l a r i f i c a t i o n can be used only when the ego i s f a i r l y healthy and can t o l e r a t e and use s e l f - s c r u t i n y with i t s accompanying a n x i e t y . 1 Planning Treatment with the Schizophrenic Patient (a)  S e t t i n g treatment goals The caseworker new to the p s y c h i a t r i c s e t t i n g or  inexperienced with the schizophrenic process,  i s prone to  make mistakes i n formulating the treatment p l a n .  Setting  treatment goals f o r the schizophrenic patient which are suitable to h i s p a r t i c u l a r needs i s dependent upon the accuracy with which the caseworker has evaluated:  the  p a t i e n t ' s motivation and capacity to use h e l p ; the presenting as well as the basic underlying problems; the needs of the p a t i e n t ; h i s ego strengths and weaknesses; and the resources a v a i l a b l e i n the community to help the c l i e n t . Due to inadequate knowledge of the psychopathology,  1 Family Service A s s o c i a t i o n of America, op. c i t . . p . 20.  88 course and prognosis of schizophrenia, the caseworker may set the treatment goals e i t h e r too high or too low, because h i s s o c i a l diagnosis  is faulty.  The caseworker may he  impressed hy the symptom-control effected by the p h y s i c a l therapies and mistakenly conclude that schizophrenia i s o r g a n i c a l l y caused and not treatable by psychotherapy.  Or  he may conclude that the schizophrenic cannot he helped by casework u n t i l h i s symptoms are eradicated hy other therapies and the patient i s again i n contact with r e a l i t y . When evidences of the disorder p e r s i s t , the caseworker may become discouraged, the p a t i e n t . "hopeless"  and set too low goals i n planning with  He may think that c e r t a i n patients  are  because the patient shows l i t t l e or no moti-  v a t i o n and judgmental a b i l i t y , and i s so out of touch with the world around him. At the other extreme are those caseworkers who consider that only intensive psychotherapy, given by a psychiatrist,  can help the schizophrenic.  attempt " i n t e n s i v e " therapy themselves, therapies, goals.  Or they may  devalue  adjunctive  and set too ambitious treatment objectives  and  They may aim at r e s o l v i n g c o n f l i c t s underlying the  d i s o r d e r , with i n s u f f i c i e n t knowledge of the schizophrenic patient's  defensive mechanisms, and stage of p e r s o n a l i t y  development.  For example, the caseworker may t r y to  resolve the "Oedipal" c o n f l i c t of a patient who never  89 reached t h i s stage of psychosexual development!  Such  ignorance leads to the s e l e c t i o n of the wrong treatment method and often r e s u l t s i n hindrance to the p a t i e n t ' s recovery, i f not actual damage and further r e g r e s s i o n . Many inexperienced caseworkers t r y to use the same approach with the schizophrenic patient which proved successful with the neurotic person's stronger ego. an approach i s bound to f a i l ,  Such  or at l e a s t disappoint the  worker when the patient f a i l s to improve.  Discouragement  may come to the caseworker from the r e a l i z a t i o n that the p a t i e n t ' s motivation i s l a c k i n g , that h i s t h i n k i n g i s impaired, that he "does not make sense" or i s " u n r e a l i s t i c " i n making plans, or that he i s unable to r e l a t e .  Deciding  on treatment goals i f the worker i s e i t h e r too p e s s i m i s t i c about schizophrenia and believes i t i n c u r a b l e , or too o p t i m i s t i c i n wanting complete recovery, can only b r i n g disappointment to the caseworker and damage to the p a t i e n t . Many caseworkers erroneously conclude that l i t t l e i n the way of psychotherapy can be achieved, so concentrate e n t i r e l y on the environment.  They note that the patient  i s "not amenable to casework s e r v i c e " meaning they have used the wrong approach and set the wrong o b j e c t i v e s . The caseworker should expect setbacks; a long period to e s t a b l i s h contact and r e l a t i o n s h i p ; slowness on the part of the patient i n gaining t r u s t ;  anger and  90 resentment when the patient f e e l s he i s not understood; and f a i l u r e of the patient to p a r t i c i p a t e i n treatment planning.  He should expect the weakened ego to the  schizophrenic to so respond, set very l i m i t e d treatment goals, but he very p e r s i s t e n t  i n f i n d i n g those  resources  both i n s i d e and outside the patient which can help i n h i s recovery.  The caseworker should c o n t r o l h i s need to do  intensive therapy, and accept the schizophrenic p a t i e n t ' s impaired capacity f o r change. The treatment objectives should be based on an o p t i m i s t i c b e l i e f that the schizophrenic patient can l e a r n to function more adequately despite h i s symptoms; that many areas of ego functioning can be strengthened by casework i f goals are r e a l i s t i c and l i m i t e d to the p a r t i c u l a r patient and h i s c a p a c i t y .  Begin where the patient  is:  help him accept h o s p i t a l i z a t i o n and treatment; help him cope with d a i l y problems on the ward; permit him to use the caseworker as a "mature parent" who gives sustenance with no expectation of emotional r e t u r n s . The two major goals with the schizophrenic patient are to e s t a b l i s h contact with the patient and gain his trust, ego.  and to help strengthen the healthy parts of the  I f these are achieved, by a i d i n g the patient each day  to cope with the r e a l i t y problems f a c i n g him, the longrange objective of a better s o c i a l adjustment f o r the  91 patient with h i s family and i n the community, w i l l (b)  result.  S e l e c t i n g the treatment method The s e l e c t i o n of the supportive or the modifying  treatment method of casework depends upon whether or not the intent i s to modify the p a t i e n t ' s ego mechanisms. 1 The question then a r i s e s :  what happens i f attempts are  made to a l t e r the schizophrenic's defenses? There i s a continuum from normal to psychotic behavior, with neurotic behavior i n the centre.  The  schizophrenic i s psychotic because he lacks defenses which maintain normal or even neurotic ego f u n c t i o n i n g .  Freud  described the f l i g h t into psychosis as a defense, an escape from r e a l i t y : the unbearable  " . . . the ego has broken away from  idea; but the l a t t e r being  inseparably  bound up with a part of r e a l i t y , i n so f a r as the ego achieves t h i s r e s u l t i t has also cut i t s e l f r e a l i t y , t o t a l l y or i n p a r t . " neurosis  loose from  Freud considered that  " . . . does not deny the existence of r e a l i t y ,  it  merely t r i e s to ignore i t ; psychosis denies i t and t r i e s to substitute something else f o r  it."  The ego has some sense of  p self-preservation,  1 Family Service A s s o c i a t i o n of America, op. c i t . . p . 15. 2 Freud, Sigmund, "The Loss of R e a l i t y i n Neurosis and P s y c h o s i s , " C o l l e c t e d Papers I I . 1924.  92  however, and t h i s f l i g h t from r e a l i t y r e s u l t s  i n symptoms  or defense formation which attempts to maintain s u r v i v a l of the p e r s o n a l i t y .  The defense mechanisms of the schizo-  phrenic ego are created to remove the patient from conflicts  so extreme that the p e r s o n a l i t y found them unbear-  able to contemplate r a t i o n a l l y .  Such symptoms are not  meaningless but have function and usefulness.  The psychosis  was a solution—the best the ego could do to ward off impending d i s a s t e r .  With the proper h e l p , the ego may be  able to dismiss i t s emergency devices or employ them more skillfully,  and resume i t s l e v e l of achievement, perhaps  to do even better than before. Treatment of the schizophrenic patient i s aimed at the maintenance of the psychotic defenses u n t i l such time as some t r u s t i s regained by the patient i n h i s environment. hostile.  He needs proof that the world i s not so  Rather than modification of h i s inner world to  adapt to r e a l i t y , he needs the environment modified so that i t i s l e s s harsh and more t o l e r a b l e .  Any tampering  with h i s defenses w i l l arouse anxiety and cause further p a n i c , regression and escape mechanisms.  Unlike the  neurotic person, who can t o l e r a t e s e l f - s c r u t i n y ,  the  reexperiencing of c o n f l i c t s and arousal of anxiety, the schizophrenic patient cannot bear to have h i s defenses pierced.  With the sociopathic p e r s o n a l i t y ,  deliberate  93 effort  i s made to have him admit to consciousness  conflicts, peutic.  and arousal of anxiety i s e s s e n t i a l  his  and thera-  The schizophrenic p a t i e n t , however, needs to  b u i l d neurotic and more constructive defenses against i n s t i n c t u a l drives and unconscious c o n f l i c t s , before he can dispense with h i s psychotic ones. It appears therefore that the supportive method of casework treatment i s the choice f o r the schizophrenic p a t i e n t , i n keeping with the c r i t e r i o n t h a t : The c l i e n t ' s adaptations are unsuccessful i n some major aspects of h i s s o c i a l f u n c t i o n i n g . The adequacy of h i s ego f o r i n t e g r a t i n g external and i n t e r n a l pressures i s so severely impaired that he can be helped only by measures that offer him support i n the c o n t r o l of h i s impulses and i n strengthening h i s constructive defenses. This need i s met hy the caseworker's p r o v i s i o n of r e a l i s t i c opportunities and experiences i n such ways as to lessen both i n t e r n a l and external pressures upon the c l i e n t ' s ego. The i n t e r n a l pressures often are caused by unconscious, u n g r a t i f i e d needs and impulses and are r e l i e v e d when c o r r e c t l y selected conscious and preconscious needs are met .1 The modifying treatment method i s not  suitable  for t r e a t i n g the schizophrenic patient since i t  requires  a s u f f i c i e n t l y strong ego to t o l e r a t e anxiety aroused by examination of c o n f l i c t s .  One c r i t e r i o n f o r choosing t h i s  method i s that the c l i e n t can t o l e r a t e f r u s t r a t i o n s ,  and  1 Family Service A s s o c i a t i o n of America, on. c i t . . p . 16  94 has the capacity for object r e l a t i o n s h i p , and for r e a l i t y testing.1  The schizophrenic patient does not have these  capacities.  The modifying method aims by c l a r i f i c a t i o n to  b r i n g to i n t e l l e c t u a l awareness those i r r a t i o n a l and unconscious c o n f l i c t s which are motivating h i s behavior and producing symptoms which cause discomfort. schizophrenic p a t i e n t ' s  The  mind, however, i s flooded with  unconscious material to such an extent that r a t i o n a l thought i s l o s t .  He cannot gain i n s i g h t by further  dis-  cussion and v e n t i l a t i o n of feelings which have already impaired normal ego functioning:  he needs to r e p r e s s , not  express, underlying c o n f l i c t s so that h i s ego i s freed to function more c o n s t r u c t i v e l y . (c)  S u i t a b i l i t y of casework to t r e a t schizophrenia In planning treatment f o r the schizophrenic  patient,  the caseworker w i l l have questioned whether case-  work i s the appropriate method, whether "psychotherapy" should be given instead by the p s y c h i a t r i s t , i n f a c t , casework i s one type of  or whether,  "psychotherapy."  F i r s t , i t appears from a survey of the  literature,  that supportive casework i s eminently suited to enhance ego functioning i n the schizophrenic.  Psychoanalysis,  more intensive therapy, as u s u a l l y employed i n the  or neuroses,  1 Family Service A s s o c i a t i o n of America, op. c i t . «  p . 20.  95 has not been so successful i n the treatment of schizophrenia,^" since i t i s based upon negative  transference  and f r u s t r a t i o n of the patient due to the  therapist's  neutral attitude.  The patient r e l i v e s e a r l y r e l a t i o n s h i p s  and f r u s t r a t i o n s but uses the transference s i t u a t i o n f o r restitution.  The transference neurosis causes regression  and i f r i g h t l y used the p a t i e n t ' s " l i b i d o " w i l l he able to attach to other objects and be freed from the s e l f .  It  can he used with the n e u r o t i c , whose ego i s strong enough to e s t a b l i s h transference, hut not with the borderline psychotic or the p s y c h o t i c , who should regress no f u r t h e r . Transference depends on t r a n s f e r r i n g a l l aggressive impulses from the i d ; also the defenses of the ego are aligned against the i d impulses.  Thus the ego i s freed  from dominance of the i d so that the p a t i e n t can become autonomous and adjust to objective r e a l i t y rather than to inner subjective r e a l i t y and l e a r n to deal with people i n a r a t i o n a l way.  To achieve t h i s the patient must be kept  i n a state of tension and anxiety and the psychotic cannot tolerate t h i s .  However, t h i s does not mean that the  psychotic cannot r e l a t e and communicate.  He can, but  cannot t o l e r a t e analysis and the transference neurosis. 1 Noyes and Kolb, op. c i t . . p . 429. 2 Prados, T . , M . D . , "Transference and Countertransference Phenomena," P s y c h i a t r i c I n s t i t u t e f o r P r o v i n c i a l Mental Health Services, Vancouver, B. C , November 1958•  p  96 Transference occurs with the schizophrenic patient but i n the opposite way to that developed with the n e u r o t i c . With the schizophrenic, transference  does not a r i s e  spontaneously as.with the n e u r o t i c .  His need f o r love and  h i s fear of not having i t met are so great that he i s ambivalent:, he i s t e r r i f i e d and t r i e s not to r e l a t e to protect himself.  Only the transfer  i s encouraged towards the t h e r a p i s t , are avoided.  of p o s i t i v e  and negative ones  Thus orthodox psychoanalysis,  i s unsuitable f o r the schizophrenic.  feelings  unless modified,  Although h i s weakened  ego w i l l permit a quick wealth of m a t e r i a l , and the t h e r a p i s t ' s i n t e r p r e t a t i o n s may be r e a d i l y accepted,  such  " i n s i g h t " i s deceptive and may cause a relapse or regression l a t e r o n . 1 In current l i t e r a t u r e , the casework method i s u s u a l l y considered to be one form of psychotherapy.  Gordon  Hamilton assumes the r o l e of the s o c i a l worker to be a therapeutic one.  " A l l s o c i a l casework has within i t  elements of 'therapy' because of the psychological use of r e l a t i o n s h i p , but i n any casework i n which attempts to counsel i n problems of human behavior i s the therapeutic elements are p e r v a s i v e . "  made,... p  Joseph contends  1 Prados, op. c i t . 2 Hamilton, Gordon, Psychotherapy i n C h i l d Guidance. Columbia U n i v e r s i t y Press, New York, 1947, p . 316.  97 that the function of psychotherapy i s to diminish anxiety, which can he achieved from a supportive, a u t h o r i t a r i a n or a n a l y t i c approach.  "We would, therefore,  assume that the  s o c i a l worker hy the very nature of h i s work i s involved i n a therapeutic f u n c t i o n . 1 , 1  In discussing the depth of  treatment, he states that i t i s more appropriate to speak of adequate versus inadequate treatment, rather than of intensive versus nonintensive. adequately when h i s f a i l u r e s  "An i n d i v i d u a l i s helped  of adaptation have been  resolved, when he can function without d e b i l i t a t i n g symptoms. I f they have not been resolved, the treatment i s  inadequate.  Nonintensive treatment goals often hide inadequate n o s t i c and consultative f a c i l i t i e s .  diag-  The worker finds himp  s e l f incapable of r e a l i z i n g maximum p o t e n t i a l . "  Joseph  defines the s o c i a l worker's r o l e as d i f f e r e n t from the psychiatrist's  i n that no attempt i s made to deal with i d  material or i t s i n t e r p r e t a t i o n , but therapy i s oriented i n terms of ego functions. There i s considerable controversy i n the as to the differences psychotherapy.  literature  between casework and other forms of  One author, Dr. Ackermanr says that i t  is  1 Joseph, Harry, M . D . , "A P s y c h i a t r i s t Considers Casework F u n c t i o n , " S o c i a l Vork. v o l . 1 , No. 2 ( A p r i l 1 9 5 6 ) , p . 9 1 . 2 I b i d . , p. 9 3 . 3 Ackerman, Nathan W., M . D . , "What Constitutes Intensive Psychotherapy i n a C h i l d Guidance C l i n i c , " The Case Worker i n Psychotherapy. Jewish Board of Guardians, .New York, 194-5» pp.  16-29.  98  dangerous to define therapy i n terms of the type of therapist.  I t must he patient oriented and f l e x i b l e .  Psycho-  therapy as p r a c t i c e d by the p s y c h i a t r i s t and the caseworker i s one of degree and not of k i n d .  He does, i n f a c t ,  advocate the t r a i n i n g of caseworkers i n psychotherapy, using the p s y c h i a t r i s t f o r consultation and guidance, and he considers caseworkers are already using many of the therapeutic s k i l l s employed by p s y c h i a t r i s t s . between therapists  "Differences  at the present time are mainly differences  i n degrees of knowledge, experience, personal aptitude and skill."1  D r . Ackerman considers that the  qualifications  for therapist include a suitable p e r s o n a l i t y make-up, t r a i n i n g and experience.  He suggests caseworkers need to  be psychoanalyzed to overcome handicaps of t h e i r i n s e c u r i t y and defects i n i n s i g h t . good therapists  " I n t u i t i v e p e r s o n a l i t i e s may make  without the a i d of psychoanalysis but with p  i t may be much b e t t e r . "  Of primary importance to act  as  therapist i s the s o c i a l s e n s i t i v i t y , capacity f o r i n s i g h t , a b i l i t y to i d e n t i f y emotionally with the p a t i e n t , emotional s t a b i l i t y and e g o - i n t e g r i t y of the caseworker. In the p s y c h i a t r i c h o s p i t a l or c l i n i c , the p s y c h i a t r i s t holds the p o s i t i o n as head of the treatment team.  The caseworker w i l l always work under h i s guidance  1 Ackerman, oo. c i t . . p . 18. 2 I b i d . , p . 28.  99 and consult him i n planning and implementing casework treatment.  The caseworker must also take i n t o account the  r o l e s played hy adjunctive therapists  (i.e.  p s y c h o l o g i s t , nurse, occupational t h e r a p i s t ,  physiotherapist, etc.)  and plan  casework service i n keeping with the approach and objectives agreed upon hy the whole team.  The r o l e of the caseworker  with a p a r t i c u l a r patient may he minimal, or he may act as p r i n c i p a l t h e r a p i s t , depending on the assignment of team members by the p s y c h i a t r i s t . (d)  Planning the structure and course of treatment The casework r e l a t i o n s h i p i s i n i t i a t e d during the  study phase of the treatment process.  Once the s o c i a l  diagnosis i s completed, however, the caseworker must p l a n steps to b u i l d and maintain t h i s r e l a t i o n s h i p hy s e t t i n g the number and length of time of the interviews, and determining t h e i r spacing.  An estimate, based upon selected  treatment goals, should he made of how long casework service w i l l continue.  During the course of treatment these plans  may a l t e r as the needs of the patient become more c l e a r . The f i n a l consideration i s planning the most suitable time to terminate s e r v i c e , and how to achieve t h i s to the best advantage of the schizophrenic.  Frequently i n the c l i n i c a l  s e t t i n g such plans are shaped hy the discharge or r e admission of the p a t i e n t . Casework with the n e u r o t i c , sociopath and c l i e n t s having f a i r l y strong egos who are oriented to r e a l i t y  100  requires careful s t r u c t u r i n g of interviews.  Such, c l i e n t s  are able to express t h e i r needs and demand help with problems.  D e f i n i t e l i m i t s are placed upon the length of time,  number and spacing of interviews, and adhered t o . controls the development of the transference  This  neurosis:  the c l i e n t i s helped to use h i s own resources and to control h i s dependency demands. In s t r u c t u r i n g interviews with the schizophrenic p a t i e n t , h i s p a r t i c u l a r needs must be taken i n t o account. For example, he may not be oriented to time and p l a c e , and w i l l have to be reminded of appointments and escorted to the interviewing room.  I f the patient finds o f f i c e  inter-  views f r i g h t e n i n g , he should be seen on the ward i n more f a m i l i a r surroundings.  The schizophrenic p a t i e n t ' s  dis-  organized ego may prevent h i s planning with the caseworker for interviews and course of treatment. i s to gain an affective  Since the intent  contact with the p a t i e n t ,  development of p o s i t i v e transference  the  i s encouraged.  Thus  the number of interviews need not be l i m i t e d , as long as the patient has expressed a wish to see the  caseworker.  Dependency on the caseworker i s encouraged so that he can develop t r u s t i n outside h e l p .  Interviews should be held  when the patient needs them, as f o r example, when he becomes disturbed over any problem.  Later on during h o s p i t a l i z a t i o n ,  regular appointments can be set i f the p a t i e n t ' s  contact  with r e a l i t y has improved so that he can understand delays  101 i n r e c e i v i n g help without f e e l i n g r e j e c t e d .  I n i t i a l l y the  schizophrenic may need to he seen every day, or at l e a s t twice weekly, to e s t a b l i s h contact and prove the caseworker's  interest. The time devoted to the interview should also be  determined by the p a t i e n t ' s  needs.  He may require two  hours of casework help on one occasion when upset, or become frightened by the intimacy of the one-to-one r e l a t i o n s h i p , and show discomfort after  a few minutes.  The caseworker i n l a t e r cases w i l l respect the  patient's  need to withdraw, and terminate the interview promptly. In short, the regressed schizophrenic patient should be interviewed, as far as i s p o s s i b l e ,  on the basis of h i s  demands and expressed needs, not i n keeping with a preconceived plan made by the caseworker. F l e x i b i l i t y i s also required on the part of the caseworker i n planning the length of treatment, terminate the r e l a t i o n s h i p .  and when to  In general, several months are  necessary to reach through the schizophrenic's defenses, and effect  any change i n h i s s o c i a l adjustment.  It  is  u n r e a l i s t i c of the caseworker to plan several years' treatment with one p a t i e n t ,  except i n a very s p e c i a l i z e d  s e t t i n g or f o r learning experience.  I f the caseworker  cannot devote several months' time, only b r i e f concrete assistance should he given, with no implied promise of a  102 deeper degree of emotional h e l p . realistic  The caseworker should he  i n appraising h i s caseload, and i n determining  the amount of time he can spend with a p a r t i c u l a r  patient,  to avoid r e j e c t i o n of the patient when he may need help the most.  He should assess how much dependency he can permit  i n the patient and s t i l l continue to meet h i s needs. Termination and evaluation of treatment,  to he further  dis-  cussed under a l a t e r s e c t i o n , w i l l he determined hy such an assessment. Implementing Treatment through the Casework Relationship The whole casework process occurs through the medium of the casework r e l a t i o n s h i p which has been defined as "the dynamic i n t e r a c t i o n of a t t i t u d e s and emotions between the caseworker and the c l i e n t , with the purpose of helping the c l i e n t achieve a better adjustment between hims e l f and h i s environment." 1  One of the c h i e f purposes of  the r e l a t i o n s h i p i s to engage the c l i e n t e f f e c t i v e l y i n the process of study, diagnosis and treatment.  The attitudes  and emotions that are the material of the i n t e r a c t i o n between caseworker and c l i e n t w i l l vary with each c l i e n t , but are based on common basic needs of people with psychos o c i a l problems.  Biestek  2  l i s t s these needs as  follows:  1 Biestek, F e l i x P . , The Casework R e l a t i o n s h i p . Loyola U n i v e r s i t y Press, 1957» P« 12. 2 I b i d . , pp. 14-17.  103 1. 2. 3. 4. 5. 6. 7.  the need to he treated as an i n d i v i d u a l the need to express f e e l i n g s the need f o r acceptance of worth and dignity the need f o r sympathetic understanding of and response to feelings expressed the need f o r a non-judgmental response the need f o r self-determination the need to have information kept confidential  In meeting these needs of the c l i e n t , the caseworker thus uses what Biestek c a l l s the Seven P r i n c i p l e s i n r e l a t i o n ship:  the p r i n c i p l e s of i n d i v i d u a l i z a t i o n ; purposeful  expression of f e e l i n g s ; acceptance;  c o n t r o l l e d emotional involvement;  non-judgmental a t t i t u d e ;  mination; and c o n f i d e n t i a l i t y . 1 s i t i v e t o , understands, needs of the c l i e n t . caseworker's  client  self-deter-  The caseworker i s  sen-  and appropriately responds to these  The c l i e n t i s somehow aware of the  s e n s i t i v i t y , understanding, and response.  In  t h i s dynamic i n t e r a c t i o n between the c l i e n t ' s needs and the caseworker's  response, treatment occurs.  "Relationship has  been c a l l e d the soul of casework, while the process of study, diagnosis,  and treatment have been c a l l e d the body."  be e f f e c t i v e ,  the r e l a t i o n s h i p depends on the  having the proper attitude  To  caseworker's  and f e e l i n g towards people;  a  knowledge and understanding of human "behavior; s k i l l s i n establishing,  1 Biestek,  maintaining and terminating the r e l a t i o n s h i p ;  oo. c i t . . pp. 14-17  2 I b i d . . p . 18.  104 knowledge and s k i l l i n a l l phases of the casework process of study, diagnosis and planning; and s k i l l i n s e l e c t i n g and u t i l i z i n g the appropriate treatment method and techniques• The caseworker has r e s p o n s i b i l i t y f o r e s t a b l i s h i n g , developing, c o n t r o l l i n g and d i r e c t i n g the r e l a t i o n s h i p i n a way which w i l l enable the f u l l e s t possible p a r t i c i p a t i o n by the c l i e n t .  He must he aware of phenomena such as  ference and r e s i s t a n c e , as they occur.  and he s k i l l f u l  trans-  i n handling these  The caseworker i s also responsible f o r the  termination of the r e l a t i o n s h i p and f o r preparing the c l i e n t for t h i s .  The c l i e n t should p a r t i c i p a t e i n t h i s as i n a l l  decisions made within the r e l a t i o n s h i p . The purpose of the casework r e l a t i o n s h i p with the schizophrenic patient i s to u t i l i z e and enhance the higher functions of the ego, such as perception, judgment and integration.  The caseworker achieves t h i s by a l i g n i n g him-  s e l f , h i s values and standards which are sanctioned and encouraged by s o c i e t y , with the healthy part of the p a t i e n t ' s ego, to help him combat the symptomatic manifestations of his i l l n e s s .  The ego i s strengthened when the patient  is  faced c o n s i s t e n t l y with r e a l i t y , and i s not l e f t to fant a s i e s , erroneous information or i r r a t i o n a l judgments.  The  caseworker represents r e a l i t y and the requirements of society.  By helping the patient cope successfully with  r e a l i t y problems, treatment gains are consolidated. Repeated experiences are digested hy the patient and used  105 f o r further growth. In treatment, those parts of the ego which s t i l l function with adequate d i s t i n c t i o n of thoughts and r e a l i t y must be employed as a l l i e s . Only with t h e i r help can the r e p a i r of the d e f i c i e n t part be a c c o m p l i s h e d . . . . The latent schizophrenic who begins to become psychotic learns to r e s i s t h i s i n c l i n a t i o n suddenly to a t t r i bute the character of c e r t a i n t y to previous ideas of reference. He himself undergoes the experience that h i s conscious, c r i t i c a l l y d i r e c t e d a t t e n t i o n i s ablepto correct the beginning f a l s i f i c a t i o n s . The engagement of the schizophrenic p a t i e n t , who fears a close r e l a t i o n s h i p , i n treatment i s achieved when the caseworker applies the Seven P r i n c i p l e s of R e l a t i o n s h i p , as outlined by Biestek, to meet the p a t i e n t ' s basic needs.  Trust w i l l be fostered i n the patient only  i f the caseworker displays by the proper attitude that he r e a l l y understands the p a t i e n t ' s i l l n e s s and i t s unfortunate effects  on behavior.  The patient should be treated as an i n d i v i d u a l with problems which are understood and accepted by the caseworker as "normal" f o r him, not viewed as he has been i n the community as "crazy" or " d i f f i c u l t . "  Since the  schizophrenic patient i s acutely s e n s i t i v e to the feelings of others, the caseworker must r e a l l y understand h i s  1 Family Service A s s o c i a t i o n of America, op. c i t . , pp. 15-19. 2 Federn, Ego Psychology and the Psychoses, p . 193*  106 i l l n e s s , not pretend t o , as such f a l s i t y w i l l he r e a d i l y detected.  The p a t i e n t ' s need to express f e e l i n g s of anger,  resentment and outrage, and at times to lose  control,  should be accepted calmly and without c r i t i c i s m . p a t i e n t learns more c o n t r o l when such outbursts ignored and not analyzed. t o l e r a t e aggression, schizophrenic.  The are  The caseworker must he able to  e s p e c i a l l y i n reaching the paranoid  The weaknesses displayed hy the patient  should be accepted f o r what they are, manifestations of h i s i l l n e s s , not character defects which make the worker f e e l hopeless about e f f e c t i n g change.  The worth and d i g n i t y of  the patient should be respected.  No matter how regressed  h i s behavior, he i s not to be treated as a c h i l d .  The  caseworker should at a l l times respond to those mature elements i n the p a t i e n t ' s p e r s o n a l i t y , not to h i s uncont r o l l e d i n s t i n c t u a l impulses. The needs of the patient can be met, and h i s t r u s t gained, only when the caseworker adopts an attitude of sympathy f o r h i s impairment, but respect f o r the fact that he i s an adult who has the r i g h t to make h i s own d e c i s i o n s . The p s y c h o t i c , by h i s commital to a mental i n s t i t u t i o n , unfortunately loses many of h i s r i g h t s to self-determination. He should be encouraged within the casework process to make decisions of which he i s capable.  Of necessity controls  are placed on the schizophrenic whose judgmental a b i l i t y i s grossly impaired, as to how h i s money i s to he spent,  107 whether he s h a l l have a s p e c i f i c treatment, e t c .  Even  then, every e f f o r t should he made to explain simply and c l e a r l y to the patient why such safeguards are deemed necessary,  and to gain h i s acceptance of medical authority  over some of h i s a f f a i r s .  The patient should be given  a l t e r n a t i v e s wherever p o s s i b l e , his  so that he can exercise  f a c u l t y f o r making d e c i s i o n s .  Excessive l i m i t s on the  p a t i e n t ' s r i g h t to choose w i l l not be imposed i f the caseworker understands that he has no r i g h t to expect normal, conventional behavior from the schizophrenic p a t i e n t , and i f he i s mature enough to t o l e r a t e d e v i a t i o n i n others. Such l i m i t s as are g r e a t l y opposed by the patient should be set by medical s t a f f .  In the casework process,  it  is  preferable to permit the patient to make repeated mistakes, even i f these r e s u l t i n relapse, p a t i e n t ' s objectives f o r him.  than to decide the  The caseworker has the  r e s p o n s i b i l i t y , of course, of making c e r t a i n that the patient r e a l i z e s the probable outcome of h i s chosen p l a n , and the consequences of h i s a c t i o n s . In e s t a b l i s h i n g a r e l a t i o n s h i p with the schizophrenic patient i t i s e s s e n t i a l that the caseworker possess sympathy and compassion, and that he l i k e the p a t i e n t , or he w i l l never t r u l y understand or a s s i s t him e f f e c t i v e l y . Even though the caseworker hides h i s d i s i n t e r e s t or impatience with the p a t i e n t ' s weaknesses, the schizophrenic  108 w i l l immediately perceive a r t i f i c i a l i t y and w i l l react by aggression,  negativism or by contemptuous i n d i f f e r e n c e . .  One basic requirement of the caseworker i n t r e a t i n g the schizophrenic i s the possession of i n t u i t i o n i n order that he may " f e e l " beneath the p a t i e n t ' s disordered and bizarre thought, h i s mutism or negativism, to the unexpressed needs and f e e l i n g s beneath.  The caseworker must believe  that supportive casework i s a method which can effect improvement i n the s o c i a l adjustment of at l e a s t some schizophrenics, and believe i n h i s own therapeutic  skills.  F i n a l l y , he must possess a parental f i b r e , to meet the needs of the patient who may have regressed to very p r i m i t i v e stages of a f f e c t i v e  development.  Both male and female  workers can assume t h i s necessary maternal, protective r o l e . Some aspects of e s t a b l i s h i n g a casework r e l a t i o n ship with the schizophrenic patient have already been mentioned under the discussion of the study phase of the casework process.  Sechehaye 1 states that i n i t i a l  contact  with the patient i s a primary and indispensable factor of any type therapy.  Often the l a t e r development of the  e n t i r e therapeutic course depends on t h i s f i r s t e s p e c i a l l y i n the case of schizophrenia.  relationship,  For schizophrenics,  who f e e l no need f o r psychotherapy, securing contact i s of  1 Sechehaye, Marguerite, A Mew Psychotherapy i n Schizophrenia. Grune and S t r a t t o n , New York, 1956, p . 24.  109 the greatest importance, and success i n e s t a b l i s h i n g contact i s already a v i c t o r y over a u t i s t i c  imperviousness.  Some schizophrenics seem to have l o s t e n t i r e l y the affective capacity to enter i n t o r e l a t i o n s h i p s with others and with r e a l i t y (even under sympathetic and understanding auspices), withdrawing i n t o t h e i r own a u t i s t i c worlds, into absolute s o l i t u d e . He has become a t h i n g , an object, and there i s s t i l l too much tendency to keep him i n t h i s mold, c l a s s i f y i n g him as a schizophrenic and admitting more or l e s s consciously h i s r e t r e a t from, the world as a t h i n g to be taken for granted. At the beginning of h i s i l l n e s s , the schizophrenic person may have searched f r a n t i c a l l y f o r contact with others. Unfortunately, by the time he i s h o s p i t a l i z e d f o r treatment, he often has given up hope, and sees himself already as an object,  an i l l person, d i f f e r e n t from others.  Once h i s  f a i l u r e i s accepted by himself and others, the schizophrenic d e l i b e r a t e l y breaks off a l l contact and shuts himself up within h i s inner subjective world, organizing a firm defense system against any attempt to communicate with him. He withdraws because he can no longer f u l f i l l  the r o l e s  demanded of him by s o c i e t y . The f a c t that he must erect such strong defenses against contact shows the schizophrenic can s t i l l react a f f e c t i v e l y to advances. He i s vulnerable to the advances of others which may upset, d i s t u r b , baffle and sometimes  1 Sechehaye, on. c i t . . p . 25  110 disconcert him. The presence of a c e r t a i n someone . . . can upset the patient and make him anxious. For him i t constitutes a threat of d i s r u p t i n g h i s subjective c i r c l e and arousing a d e s i r e , a need which i s nearly always disappointed.1 According to t h i s author, an intense a f f e c t i v e  state i s  concealed beneath the schizophrenic's defenses of i n d i f ference, negativism, a g i t a t i o n , p a s s i v i t y , stereotypy, and absurdity.  Each patient reacts d i f f e r e n t l y to attempts  at  contact, but even the most remote p a t i e n t , sunk i n h i s dreams, i s s t i l l able to f e e l the presence of another person and i s often moved by h i s advances.  The caseworker must  understand the schizophrenic's defenses, and why they are erected, before employing the appropriate techniques of the supportive treatment method to e s t a b l i s h and maintain the casework r e l a t i o n s h i p . The most frequent defense i n schizophrenia i s an i n d i f f e r e n t attitude to mask the p a t i e n t ' s intense desire f o r dependency. reactions.  It i s found i n a l l types of schizophrenic  Negativism i s seen i n those patients who refuse  to answer questions, turn t h e i r backs on the questioner, and become h o s t i l e and furious i f one i n s i s t s  on contact.  In acute and e a r l y stages of schizophrenia, the patient frequently becomes agitated,  t a l k s e a s i l y , confides, asks  1 Sechehaye, op. c i t . , p . 26  Ill advice—but gains no r e l i e f by t h i s communication, and i n fact becomes more anxious.  The patient only experiences  emptiness and despair because such s u p e r f i c i a l contact has not s a t i s f i e d h i s intense desire to reach another person. Such f r a n t i c efforts  to gain contact are also found i n the  chronic schizophrenic, although these are aimlessly d i r e c t e d and l e s s purposeful.  P a s s i v i t y i s another form of defense  against contact, varying a l l the way to catatonic r i g i d i t y : the patient takes refuge within h i s body and r e s i s t s h i s surroundings hy an impenetrable a t t i t u d e , with movements reduced to a minimum.  On the same body and motor l e v e l  are stereotyped movements and v e r b a l i z a t i o n s which are used to shut out the i n t r u d e r .  Absurdity of conduct i s e x h i -  b i t e d p a r t i c u l a r l y hy hebephrenics who execute a l l types of disordered, meaningless gestures, shouting, laughing, e t c . and seem to lose a l l sense of shame and r e s t r a i n t . I t i s d i f f i c u l t to penetrate to the more serious l e v e l beneath without meeting resistance i n such p a t i e n t s . 1 Such defenses are caused by f e a r .  The schizo-  phrenic i s a f r a i d of reawakening emotional a c t i v i t y , and t r i e s to f e e l nothing. and hence p a i n .  Personal contact may arouse f e e l i n g  The patient may fear a collapse of h i s  psychotic e q u i l i b r i u m , the regressed existence he has created to protect him from being hurt by p a i n f u l  1 Sechehaye, on. c i t . . pp. 26-35.  112 encounters with r e a l i t y .  Some patients fear that emotional  arousal w i l l bring aggression and assume p a s s i v i t y as a defense.  The paranoid fears l o s i n g h i s l i b e r t y , of being  subjected to the w i l l of another person i f he enters a relationship.  Defenses are also r a i s e d i n the schizophrenic  due to the constant sense of g u i l t which formed before the superego developed, and i s not l i k e the n e u r o t i c ' s g u i l t feelings.  The patient fears to break what to him are moral,  i n e v i t a b l e laws that he must not transgress. typed a t t i t u d e s ,  such as the delusion of a voice forbidding  the patient to eat, are d i f f i c u l t defenses  These stereo-  to a l t e r .  Finally,  are assumed to protect the patient from shame  and embarrassment.  The patient fears to be treated again  as a "subject" and be held responsible f o r h i s a c t i o n s .  He  fears l o s s of the contentment he has found i n h i s world of fantasy,  where he i s merely an " o b j e c t . " 1  2 Most of the supportive treatment techniques  are  appropriate f o r conquering the schizophrenic's resistance to contact, and to strengthen h i s ego functioning, the treatment process.  during  The caseworker's presence as a  part of the p a t i e n t ' s l i f e and h i s world, h i s r e a l i s t i c outlook i n helping the patient correct misconceptions i n perception and t h i n k i n g , gives reassurance and stops the 1 Sechehaye, oo. c i t . . pp. 35-44. 2 Family Service A s s o c i a t i o n of America, oo. c i t . , pp. 17-18.  113  i n t e r n a l destruction taking p l a c e .  The caseworker w i l l  approve r e a l i s t i c achievements and decisions made hy the patient and encourage r e a l i t y - o r i e n t a t i o n .  By g i v i n g  information to the p a t i e n t , e s p e c i a l l y when h i s knowledge of means to achieve what he wants i s l i m i t e d or i n c o r r e c t , the patient i s strengthened and helped to a t t a i n hos goals. L o g i c a l discussion a s s i s t s the p a t i e n t with impaired assessment and judgmental functions to perceive and appraise r e a l i t y , to assess a l t e r n a t i v e s and to anticipate the consequences of h i s a c t i o n s .  Due to the breakdown i n the  schizophrenic's l o g i c a l t h i n k i n g , t h i s technique, u t i l i z i n g the caseworker's stronger higher ego functions, i s espec i a l l y useful to help the patient make more constructive decisions.  The schizophrenic p a t i e n t , who has l o s t h i s own  sense of personal i d e n t i t y , i s quick to i d e n t i f y with persons i n h i s environment.  Thus when i n the r e l a t i o n s h i p ,  the caseworker demonstrates behavior which i s more r e a l i s t i c and s o c i a l l y acceptable,  the patient r e a d i l y  imitates and i n time i n t r o j e c t s such responses which leads to h i s own b e t t e r  adjustment.  In g i v i n g advice and guidance, the caseworker uses h i s p r o f e s s i o n a l knowledge and a u t h o r i t y i n guiding the patient towards more constructive behavior and solutions to h i s problems.  The regressed schizophrenic often seeks  such d i r e c t i o n , as from a parent, and finds s e c u r i t y from such a technique, since he has given up hope of f i n d i n g  114 any s o l u t i o n himself.  Of primary importance i s the t e c h n i -  que of s e t t i n g r e a l i s t i c  l i m i t s with the schizophrenic  patient whose own sense of r e a l i t y i s impaired.  Often the  patient cannot perceive that h i s behavior w i l l b r i n g moral and s o c i a l disapproval,  and needs the caseworker's standards  and values to strengthen h i s own superego.  The caseworker  should always be very frank and honest i n p o i n t i n g out to the patient the l i m i t s set by society on behavior, and encourage him to adhere to such standards, even though he resents such conformity. able to avoid d i f f i c u l t i e s  Only then w i l l the patient be with the law and the community.  The patient who cannot adjust to such l i m i t s w i l l need a protected environment after h i s discharge,  such as a  boarding home, although even here a c e r t a i n degree of conformity w i l l be r e q u i r e d .  Another technique which i s  always used with the schizophrenic patient i s  direct  i n t e r v e n t i o n by the caseworker i n the p a t i e n t ' s environment. This may involve changing any s i t u a t i o n to make r e a l i t y more t o l e r a b l e to the l i m i t e d c a p a c i t i e s of the schizophrenic, or a l t e r i n g the attitudes of the p a t i e n t ' s and r e l a t i v e s .  friends  For the chronic schizophrenic whose capacity  to change i s minimal, such environmental modification i s imperative.  The use of h a b i t u a l patterns of behavior i s a  technique which aims at improving the p a t i e n t ' s  social  functioning by the acceptance of more conventional behavior. Most schizophrenic patients are quite capable of gaining a  115 r e a l i z a t i o n that they cannot express unpopular behavior and delusions without the consequence of another committal to hospital.  Such pressures to c o n t r o l s o c i a l l y disapproved  ideas and conduct i s necessary i f the patient i s to l i v e again i n the community, even though i t does not modify h i s i n t e r n a l p a t h o l o g i c a l processes.  Although he may s t i l l  think and want to act p a t h o l o g i c a l l y , the patient can be t r a i n e d not to p u b l i c l y do so. The two techniques which should be avoided, or used only i n s p e c i f i c cases where ego functioning i s strong,  are v e n t i l a t i o n and confrontation.  fairly  Catharsis  or  the venting of emotions attached to persons i n the p a t i e n t ' s past and current s i t u a t i o n i s u s u a l l y hazardous with the schizophrenic p a t i e n t .  The expression of negative  feelings  should be l i m i t e d since t h i s only weakens the p a t i e n t ' s defenses against i n s t i n c t u a l impulses.  Free association  ideas connected with p a i n f u l emotional experiences dangerous.  The patient should not, for instance,  encouraged to discuss at length experiences  is  of  also  be  with r e l a t i v e s  i n h i s past and present i f such topics cause emotional distress.  The caseworker should also be cautious i n con-  f r o n t i n g the patient with behavioral patterns and episodes if  such s e l f - s c r u t i n y upsets him.  His ego i s u s u a l l y not  strong enough to t o l e r a t e an examination of h i s unpopular behavior and other techniques can be employed more t a c t f u l l y to b r i n g the degree of self-awareness he i s  able  116 to  tolerate. The approaches used hy the caseworker i n main-  t a i n i n g the treatment r e l a t i o n s h i p have been i n d i r e c t l y discussed i n the examination of the study, n o s t i c and planning phases. successful  social  diag-  Some a d d i t i o n a l guides to  treatment of the schizophrenic patient might he  summarized h e r e . 1  In general,  the caseworker should he  scrupulously honest with the patient and not t r y to overprotect him from r e a l i t y .  He should attempt to e s t a b l i s h  r e a l confidence and t r u s t beyond a s u p e r f i c i a l The patient  rapport.  should he permitted to express h i s own view-  point and share i n seeking solutions to environmental problems.  Of n e c e s s i t y , interviews must he based on a  sound knowledge, not only of the psychodynamics, but of the psychopathology,  of the p a t i e n t .  Manifestations  psychosis can be discussed but i n t e r p r e t a t i o n s symptoms are r a r e l y given. patient,  of the  of such  Solutions o r i g i n a t i n g with the  even i f o f f e r i n g but l i t t l e ,  should he seized upon  and emphasized hy frequent r e p e t i t i o n on the part of the caseworker.  The p a t i e n t ' s reaction timing should be  respected and allowances made f o r the p a t i e n t ' s slowness i n taking a c t i o n on a s p e c i f i c p l a n .  C e r t a i n patients w i l l  need d i r e c t i o n and guidance s i m i l a r to that given young  1 Fromm-Reichmann, Freda, "Psychotherapy of Schizophrenia," Psychoanalysis and Psychotherapy. The U n i v e r s i t y of Chicago . Press, Chicago, 1959, pp. 194-209.  children.  117  S i l e n t p a r t i c i p a t i o n on the part of the case-  worker, as well as acceptance  of a l l mannerisms, i m i t a t i o n  of words and even gestures, r e p e t i t i o n and sharing are a l l effective  i n f o s t e r i n g the r e l a t i o n s h i p .  The patient  should he prepared well i n advance f o r anything that  is  going to happen to him to allow f o r h i s slow timing.  The  casework goals are l i m i t e d to helping each patient reach h i s own best p o s s i b i l i t i e s  and to adjust to the n e c e s s i t i e s  of l i v i n g , and to help r e l a t i v e s  and others accept the  patient as he i s . Termination of the casework r e l a t i o n s h i p with the schizophrenic patient poses c e r t a i n problems not found with l e s s depleted c l i e n t s .  Due to the nature of h i s  illness,  the schizophrenic probably had broken any r e a l contact with people i n the community by h i s wothdrawal p r i o r to hospitalization.  Unless these have been renewed while he  was undergoing treatment,  the patient w i l l f i n d he i s  alone at the point of discharge,  with no one to turn t o .  A large percentage of schizophrenic persons have l i v e d solitary,  l o n e l y l i v e s for years before t h e i r breakdown,  and t h e i r r e l a t i o n s h i p with the caseworker may be t h e i r only r e a l " f r i e n d s h i p . "  It i s important that some resource  be found i n the community—family, f r i e n d s ,  living situ-  a t i o n , employment, agency h e l p , etc.—which w i l l offer a substitute s a t i s f a c t i o n  f o r the schizophrenic patient  before contact i s broken with the h o s p i t a l  caseworker.  118 The t r u s t gained i n the l a t t e r r e l a t i o n s h i p w i l l graduallythen he transferred to an outside person. The caseworker should not arouse deep dependency i n the schizophrenic and then suddenly terminate contact. This i s much more important i n t r e a t i n g the schizophrenic person than the n e u r o t i c , who can r e l a t e more e a s i l y and find a substitute.  The schizophrenic w i l l only he  shattered by the l o s s of intimacy and probably suffer relapse.  Termination should therefore he gradual.  a  Even  monthly telephone contacts, with home v i s i t s during c r i s e s , are h e l p f u l i n maintaining the improvement gained by hosp i t a l treatment.  Or the caseworker may offer  consultative  services to a community agency which w i l l offer continued support and improvement i n the p a t i e n t ' s home s i t u a t i o n . In any event, the c l i n i c a l caseworker should bridge the gap between the h o s p i t a l and the community u n t i l such time as the patient i s again s e t t l e d i n s o c i e t y .  119  Concluding Summary Schizophrenia i s such a vast and complex subject for study that d e f i n i t e l i m i t s have been set i n discussing casework treatment of t h i s d i s o r d e r . most common of the psychoses,  Schizophrenia, the  i s seen as a chronic and  severe mental c o n d i t i o n , which u s u a l l y requires h o s p i t a l treatment. defined:  The cause of schizophrenia i s not c l e a r l y there i s no evidence of successful prevention of  t h i s d i s o r d e r , and no proven cure e x i s t s . The conclusions of t h i s t h e s i s are based upon the assumption that schizophrenia i s psychogenic i n o r i g i n , beginning i n e a r l y childhood when extreme anxiety and i n s e c u r i t y i n the c h i l d are caused by f a u l t y r e l a t i o n s h i p s with the parents,  and i n p a r t i c u l a r with the mother.  Psychotherapy i s considered to be the most suitable  treat-  ment f o r schizophrenia, with adjunctive p h y s i c a l therapies used to reduce symptoms and increase a c c e s s i b i l i t y to personal contact.  The schizophrenic p a t i e n t ' s  central  problems have been defined as h i s withdrawal from r e a l i t y due to f e a r ,  and h i s basic mistrust of people.  A reality-  oriented treatment approach, d i r e c t e d to helping the patient cope more e f f e c t i v e l y with everyday problems, i s used to overcome the schizophrenic p a t i e n t ' s h i s contact with the r e a l worldx.  distrust  and to renew  120 In schizophrenia, there i s a weakening or breakdown of ego functioning which r e s u l t s i n abnormal thought, perception and behavior due to a d i s s o c i a t i o n with r e a l i t y . Basic mistrust i n people, stemming from e a r l y childhood, results  i n i n a b i l i t y to form and maintain object r e l a t i o n -  ships.  The process of casework can he used to help  strengthen the schizophrenic p a t i e n t ' s ego, b r i n g him i n c l o s e r contact with r e a l i t y , and enable him to form more intimate and s a t i s f y i n g r e l a t i o n s h i p s hy gaining some t r u s t i n the caseworker which u l t i m a t e l y i s transferred to others. Examination of the two casework treatment methods—supportive and modifying—indicate that supportive casework i s eminently suited f o r treatment of the schizophrenic patient.  Because the schizophrenic p a t i e n t ' s defenses are  such that he cannot t o l e r a t e the s e l f examination involved i n c l a r i f i c a t i o n , catharsis,  and i n t e r p r e t a t i o n of under-  l y i n g c o n f l i c t s , the modifying treatment method i s not appropriate.  The casework approach to the schizophrenic  d i f f e r s decidedly from that used with c l i e n t s possessing stronger egos, such as the neurotic and sociopathic pers o n a l i t i e s , who can t o l e r a t e the anxiety aroused by s e l f scrutiny.  The goals of casework with the schizophrenic  patient i s support of the constructive parts of the p a t i e n t ' s p e r s o n a l i t y , strengthening of h i s ego-functioning, and maintenance of h i s psychotic defenses u n t i l more cons t r u c t i v e defenses are r e b u i l t .  The techniques employed  i n the supportive treatment method are suited to these goals.  121 Treatment objectives with the schizophrenic patient should he r e a l i s t i c and l i m i t e d to the handicaps imposed by t h i s disorder i n ego f u n c t i o n i n g .  Schizophrenic  patients are able to r e l a t e and respond i n the casework r e l a t i o n s h i p i f treatment goals are i n keeping with the underlying p e r s o n a l i t y s t r u c t u r e .  Continued supportive  measures help the schizophrenic patient improve h i s d a i l y s o c i a l functioning and increase h i s perception of the r e a l world. This study has been l i m i t e d to discussion of only one aspect of casework with the schizophrenic p a t i e n t ,  that  of enhancing ego functioning through m o b i l i z i n g of the constructive parts of the p e r s o n a l i t y .  The e s s e n t i a l com-  plement to t h i s aspect of casework—that i s , m o b i l i z a t i o n of resources outside the patient i n the way of family, f r i e n d s , employment and other resources i n h i s environment, have not been examined.  F i n a l l y , the use of case examples  to i l l u s t r a t e the actual process of treatment with the schizophrenic p a t i e n t , have not been used, although these would have helped greatly to c l a r i f y the d i s c u s s i o n .  These  two areas, use of environmental resources to bridge the gap to r e a l i t y f o r the schizophrenic p a t i e n t , and i l l u s t r a t i v e examples of casework techniques i n t r e a t i n g schizophrenia, would both afford f r u i t f u l further  research.  subjects f o r  APPENDIX A BIBLIOGRAPHY Ackerman, Nathan to*., M.D. "Mental Hygiene and S o c i a l Work, Today and Tomorrow." S o c i a l Casework, v o l . 36, No. 2 (February 1955), pp. 63-70. Ackerman, Nathan W., M.D. "What Constitutes Intensive Psychotherapy i n a C h i l d Guidance C l i n i c . " The Case Worker i n Psychotherapy. Jewish Board of Guardians, New York, 19^5, pp. 16-29. American P s y c h i a t r i c Association Mental Hospital Service, Diagnostic and S t a t i s t i c a l Manual of Mental Disorders. Washington, 1952. Appel, Kenneth E . "Mental Health and Mental I l l n e s s . " S o c i a l Work Yearbook 1957. American Association of S o c i a l Workers, New York, 1957, pp. 363-371. A r i e t i , S i l v a n o , M.D. Interpretation Robert Brunner, New York, 1955.  of Schizophrenia.  Axelbrad, S. "Symposium: Progress i n Orthopsychiatry." American Journal of Orthopsychiatry, v o l . 25 (1955), pp. 524-538. Beck, S. J . "The Six Schizophrenias." American Orthopsvchiatric A s s o c i a t i o n : Research Monograph V I . American Orthopsychiatric A s s o c i a t i o n , New York. B e l l a k , Leopold, M . D . , ed. Schizophrenia: a Review of the Syndrome. Logos Press, I n c . , New York, 1958. Beres, David. "Ego Deviation and the Concept of Schizophrenia." Psychoanalytic Study of the C h i l d ,  v o l . 11 (1956), pp. 164-235.  Biestek, F e l i x P. The Casework R e l a t i o n s h i p . Loyola U n i v e r s i t y Press, Chicago, 1957* B l e u l e r , Eugen. Dementia Praecox or the Group of Schizophrenias. Translated by Joseph Z i n k i n , International U n i v e r s i t y Press, New York, 1950.  123 B r i t i s h Columbia P r o v i n c i a l Mental Health S e r v i c e s . P h y s i c i a n ' s Manual. 1956. Bowers, 0. M. I. "The Nature and D e f i n i t i o n of S o c i a l Casework." S o c i a l Casework, v o l . 30, No. 10 (December  1949).  Coleman, J u l e s . "Psychotherapeutic P r i n c i p l e s i n Casework Interviewing." American Journal of Psychiatry, v o l . 108, No. 4 (October 195D. Davidson, Evelyn H. "Therapy i n Casework." S o c i a l Work, v o l . 12, No. 3 (July 1955), pp. 80-91. E i s s l e r , K. R. "Remarks on the Psychoanalysis of Schizophrenia." Psychotherapy with Schizophrenia: a Symposium. International U n i v e r s i t y Press, New York,  1952.  E l l s w o r t h , Robert B . , P h . d . , with Beverley T. Mead, M . D . , and William H. Clayton, M.S.W. "The R e h a b i l i t a t i o n and D i s p o s i t i o n of C h r o n i c a l l y H o s p i t a l i z e d Schizophrenic P a t i e n t s . " Mental Hygiene, v o l . 42, No. 4 (July 1958), pp. 343-348. Family Service Association of America. Method and Process i n S o c i a l Casework. New York, 1958. Federn, P a u l . Ego Psychology and the Psychoses. Basic Books, New York, 1952. Frechtman, Bernice W. and Committee. "Report of the Committee on the Role of the P s y c h i a t r i c Worker as Caseworker or T h e r a p i s t . " Journal of P s y c h i a t r i c S o c i a l Work, v o l . 20 (l950Xi Freeman, Thomas, John L . Cameron and Andrew Mcghie. Chronic Schizophrenia. Tavistock P u b l i c a t i o n s , London, 1958. F r i e d l a n d e r , Walter A . Introduction to S o c i a l Welfare. P r e n t i c e - H a l l , I n c . , New York, 1955. Freud, Sigmund. "The Loss of R e a l i t y i n Neurosis and Psychosis." Collected Papers I I . 1924. Fromm-Reichmann, Freda. "Psychotherapy of Schizophrenia." Psychoanalysis and Psychotherapy. The U n i v e r s i t y of Chicago Press, Chicago, 1959, pp. 194-209.  124 Gaw, Emir A . , M . D . , with Suzanne Reichard, P h . d . , and C a r l T i l l m a n , M.D. "How Common i s Schizophrenia?" B u l l e t i n of the Menninger C l i n i c , v o l . 17 (1953), pp. 21-28. Ginsburg, Sol Wiener. "Special Comment" (a review of S o c i a l Class and Mental I l l n e s s : a Community Study, hy August B. Hollingshead and Fredrick C. R e d l i c h , Published hy John Wiley and Sons). American Journal of Orthopsychiatry, v o l . 29, No. 1 (January 1 9 5 9 ) » pp. 192-201. Hamilton, Gordon. Psychotherapy i n C h i l d Guidance. Columbia U n i v e r s i t y Press, New York, 1947. Joseph, Harry, M.D. "A P s y c h i a t r i s t Considers Casework F u n c t i o n . " S o c i a l Work, v o l . 1, No. 2 ( A p r i l 1956). K l i n e , Nathan S., M.D. Synopsis of Eugen B l e u l e r 1 s Dementia Praecox or the Group of Schizophrenias. International U n i v e r s i t i e s Press, I n c . , New York,  1957.  Knee, Ruth I r e l a n . " P s y c h i a t r i c S o c i a l Work." S o c i a l Work Yearbook 1957. American Association of S o c i a l Workers, New York, 1957, pp. 431-439. Landy, David. " C u l t u r a l Antecedents of Mental I l l n e s s i n the United S t a t e s . " The S o c i a l Service Review (December 1958), pp. 350-361. Menninger, K a r l , M.D. "The Diagnosis and Treatment of Schizophrenia." B u l l e t i n of the Menninger C l i n i c , v o l . 12, No. 3 (1948), pp. 96-106. Menninger, K a r l , M . D . , with Henri Ellenberger, M . D . , Paul Pruyser, P h . d . , and Martin Mayman, P h . d . "The Unitary Concept of Mental I l l n e s s . " B u l l e t i n of the Menninger C l i n i c , v o l . 22, No. 2 (March 1958), pp. 4-12. Noyes, Arthur P . , M . D . , and Laurence C. Kolb, M.D. Modern C l i n i c a l Psychiatry. 5th ed. W. B. Saunders C o . , P h i l a d e l p h i a , 1958. Opler, Marvin K . , P h . d . " C u l t u r a l Perspectives i n Mental Health Research." American Journal of Orthopsychiatry, v o l . 25, No. 1 (January 1955), pp. 51-58. Parad, Howard J . , ed. Ego Psychology and Dynamic Casework. ' Family Service Association of America, New York, 1958.  125 Perlman, Helen Haxris. S o c i a l Casework. The U n i v e r s i t y of Chicago Press, Chicago, 1957* Riesman, David, with Nathan Glazer and Reuel Denney. The Lonely Crowd. Doubleday and Company, I n c . , New York, 1955. Sechehaye, Marguerite. A New Psychotherapy i n Schizophrenia. Grune and S t r a t t o n , New York, 1956.  

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